Charles 2

D

42. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? a. Reaffirm the client's desire for no resuscitative efforts. b. Transfer the client to a hospice inpatient facility. c. Prepare the family for the client's impending death. d. Notify the healthcare provider of the family's request.

ABC

6) A nurse should teach a client with angina about the common side effects of nitroglycerin, including: Select all that apply. A. Headache. B. Hypotension. C. Dizziness. D. Shortness of breath. E. Abdominal cramps.

B (?)

) Which IV fluid order is most appropriate for a client on dialysis? A. D5 1/2NS at 20 mL/hr. B. NS at 150 mL/hr. C. 1/4NS with 20 mEq KCl at 75 mL/hr. D. D10W with 40 mEq KCl at 50 mL/hr.

C (?)

2) Which finding indicates that epoetin alfa (Epogen) has been effective? A. Negative Homans' sign, aPTT of 35 to 55 B. Guaiac-negative gastric secretions and stool. C. Hematocrit of 33%. D. Creatinine of 1.4.

B

3) Teaching for a client starting on spironolactone (Aldactone) should include: A. The importance of removing the patch at bedtime. B. Food sources to replace lost potassium. C. The purpose of this drug is to prevent fibrosis in the heart. D. Taking the medication just before bed.

A ir b

7) A client with a sexually transmitted infection (STI) is to receive azithromycin. Before the medication is given, which nursing assessment is a priority? A. Obtain a CBC. B. Ask the client about allergies. C. Check the blood pressure. D. Ask the client about sexual contact.

A

4) Before administering furosemide (Lasix), a nurse should verify that: A. The blood pressure is under 180/90 mm Hg. B. The potassium is over 4 mg/dL. C. There are no crackles in the lungs. D. The client has an indwelling catheter in place.

A

7. A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? a. Place the client on seizure precautions and monitor carefully. b. Immediately transfer the client to ICU. c. Describe the symptoms to the charge nurse and record on the client's chart. d. No action is required at this time as these are known side effects of such drugs.

C

A client had a cast applied to the left femur to stabilize a fracture. To promote early rehabilitation, the nurse should first: BTW, teaching is consider part of psych. A. show the family how to do active range-of-motion exercises of the unaffected limb. B. call physical therapy to provide passive exercise of the affected limb. C. teach the client how to do isometric exercise of the quadriceps. D. obtain weights so the client can exercise the upper extremities.

A

A client is 1 day postoperative for a stereotactic brain procedure for relief of compulsive behavior. For which complication should a nurse observe this client? A.Altered level of consciousness. (think by system) B. Immobility. C. Electrolyte imbalance. D. Infection.

C

A client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (anti-nausea) medication. The nurse recognizes that which of the following is accurate? a. An enteric-coated medication should be given. b. Medication will not be absorbed as easily because of the nausea. c. A parenteral route is the route of choice. d. A rectal suppository must be administered.

A

A client is on lithium for management of bipolar disorder. Which signs and symptoms should indicate to a nurse that the client is at risk for severe toxicity? A. Lethargy and motor weakness. ( B. Hand tremors. C. Tardive dyskinesia. D. Pruritus.

C

A client is responding with hostility to staff and other clients. A nurse's priority diagnosis for this client should be: A. Distorted sensory perception. B. Impaired social interaction. C. Risk for violence. D. Impaired thought processes.

D

A client receiving Doxorubicin (Adriamycin) intravenously (IV) complains of pain at the insertion site, and the nurse notes edema at the site. Which intervention is most important for the nurse to implement? a. Assess for erythema. b. Administer the antidote. c. Apply warm compresses. d. Discontinue the IV fluids.

D

A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? a. What dose of medication are you taking? b. Are you eating foods rich in potassium? c. Have you lost weight recently? d. At what time do you take your medication?

C

A client was recently diagnosed with depression related to loss of a spouse. The client describes thinking constantly about the relationship and dreams of reconciliation even though the spouse is deceased. (assessment finding) A nurse should document this as: A. Omnipotence. B. Isolation of affect. C. Fantasy. D. Regression.

B

A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer. • 1_"Rinse your mouth." • 2_"Attach the spacer." • 3_"Press down on the inhaler once and breathe in slowly." • 4_"Take off the cap and shake the inhaler." • 5_"Hold your breath for at least 10 seconds, then breathe in and out slowly." • 6_"Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." • Really a fundamentals med administration question. A. 4, 2, 3, 6, 5, 1 B. 4, 2, 6, 3, 5, 1 C. 4, 2, 5, 6, 3, 1 D. 2, 4, 5, 6, 3, 1

A

A client with type 1 diabetes mellitus must learn how to self-administer insulin. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? A. "Rotate injection sites within the same anatomic region." B. "Inject insulin into subcutaneous tissue with large blood vessels nearby." C. "Rotate injection sites among different regions." D. "Administer insulin into sites near muscles that you plan to exercise."

A

A client with type 2 diabetes who requires insulin asks the nurse about having alcoholic beverages. Which is the best response by the nurse? A. "You can have one or two drinks a day as long as you have something to eat with them." B. "If you have a drink, the blood glucose value may be elevated at bedtime, and you should skip having a snack." C. "if you are going to drink, it is best to consume alcohol on an empty stomach." D. "Alcohol is detoxified in the liver, so it is not a good idea for you to drink anything with alcohol."

D

A client's family reports clinical manifestations of hyperactivity, delusions of grandeur, (key symptom) impaired judgment, and inability to sit still during a meal. (assessment findings) Which diagnosis should a nurse suspect? A. Attention deficit-hyperactivity disorder (ADHD). B. Attention deficit disorder (ADD). C. Psychosis. D. Mania.

A

A nurse assesses a client suspected of taking opiates. Which pupil size/shape represents opiate intoxication? A. 1 (narcs—tiny pupils—recall) B. 2 C. 3 D. 4

C

A nurse is caring for a client who is diagnosed with psychogenic diabetes insipidus. Which laboratory value is most indicative of this condition? A. Serum glucose of 65 mg/dL. B. Serum Na of 130 mEq/L. C. Serum Na of 150 mEq/L. Fluid down, sodium up D. Serum glucose of 129 mg/dL.

Abe

A nurse is caring for a client who is experiencing serotonin syndrome. Which serotonergic drugs should a nurse recognize as possibly contributing to this problem? Select all that apply. (Like most pharm problems, you really have to just know this—suggest flash cards—old fashioned but effective.) A. Duloxetine (Cymbalta). B. Fluoxetine (Prozac). C. Aripiprazole (Abilify). D. Haloperidol (Haldol). E. Paroxetine (Paxil).

Abd

A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply. A. Provide small, frequent meals B. Encourage the client to keep a journal C. Encourage the client to eat three substantial meals per day ineffective D. Monitor weight gain E. Allow the client to skip meals until the antidepressant levels are therapeutic Unsafe

D

A nurse is inserting a nasogastric (NG) tube on an adult client, and, during the procedure, the client begins to cough and have difficulty breathing. The priority action at this time is which of the following? a. Quickly insert the NG tube. b. Remove the tube, and notify the physician. c. Remove the tube, and reinsert when the client fully recovers. d. Pull back on the tube, and wait until the client is breathing easily.

D

A nurse is providing an education in-service about low-residue diets to a group of clients with colitis in a public health clinic. Which of the following diet choices would show that teaching has been effective? A. Baked fish, macaroni with cheese, strained carrots, fruit gelatin, and milk B. Cream soup and crackers, omelets, mashed potatoes, peas, orange juice, and coffee C. Stewed chicken, baked potatoes with butter, strained peas, white bread, plain cake, and milk D. Lean roast beef, buttered white rice with egg slices, white bread with butter and jelly, and tea with sugar

B

A nurse is reviewing the laboratory values for a group of clients in a psychiatric emergency department. Prioritize each laboratory result from most to least important to report to a physician. _______1. The client taking clozapine (Clozaril) with a WBC count of <3000/mm3. _______2. The client with bipolar disorder and a lithium level of 1.6 mEq/L. _______3. The client with a blood alcohol level of 0.08%. _______4. The client with schizoaffective disorder and a potassium level of 6.0 mEq/L. Maslow—Circulation—first to be first. Number 3/ borderline impaired—last. WBCs at 3 is more acute than lithium of 1.6—even though that's double the high therapeutic level.) A. 1,4,2,3 B. 4,1,2,3 C. 4,1,3,2 D. 1,4,3,2

B

A nurse organizes a community action group to help resolve health problems in a low income neighborhood with a large population of recent immigrants from Africa. What problem should the nurse address first? a. High rate of unemployment. b. Low immunization rate of children. c. Provision of substandard health care. d. Access to bilingual care providers.

D

A nurse records a client's history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the client control? A. Diabetes, age, and gender B. Age, gender, and heredity C. Diabetes, hypercholesterolemia, and heredity D. Diabetes, hypercholesterolemia, and hypertension

B

A nurse's priority related to clients who are experiencing clinical manifestations of borderline personality (assessment finding disorder should be to: A. Increase therapeutic communication when the client exhibits intrusiveness. B. Set limits when the client exhibits threats of self-damaging behaviors. C. Engage in one-to-one discussions about childhood experiences. D. Employ behavior modification using covert techniques.

C

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of the following assessment findings indicates an acute pain response to poorly controlled pain? a. Confusion b. Hyperventilation c. Increased blood pressure and pulse d. Decreased blood pressure and pulse

C

A physician orders trihexyphenidyl (Artane) 4 mg at bedtime to relax a client's rigid muscles. The elixir is dispensed as 2 mg/5 mL. A nurse should correctly instruct the client to take _______ teaspoons of this medication. A. 10 B. 5 C. 2 D. 1/2

A

A physician prescribes haloperidol decanoate (Haldol Decanoate) 0.5 mg IM to a client diagnosed with schizophrenia. Haldol Decanoate is available as a 2-mg/mL solution for IM injection. In order to administer the correct dosage, a nurse should inject _______ mL intramuscularly. A. 0.25ml B. 0.5ml C. 1ml D. 4ml

A

After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent: (first step of the nursing process—assessment) A. "What concerns do you have about vaccinations?" B. "Would you prefer that fewer vaccines are given at a time?" C. "Can you please sign this vaccine waiver form?" D. "Did you know that vaccinations are required by law for school entry?"

C

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? a. Request another nurse to complete the physical assessment. b. Ask the client to stop crying and tell the nurse what is wrong. c. Acknowledge the client's distress and tell her it is all right to cry. d. Leave the room so that the client can be alone to cry in private.

C

During an assessment of hydration status, the client tells the nurse that she drank 3 quarts of liquids the day before. What will the nurse ask next? a. "Were the liquids hot or cold?" b. "How much salt do you add to your food?" c. "What kinds of liquids do you usually drink?" d. "Do you drink fluids with meals or between meals?"

C (Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance. The client should remain NPO, and a soap suds cleansing enema is not indicated. Decompressing the stomach should alleviate the nausea, but if antiemetics are ordered, they would not take priority over decompressing the stomach.)

The nurse is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food after breakfast. Which intervention will the nurse prepare to do for the client? a. Administer a soap suds cleansing enema. b. Change the client's diet to clear liquids only. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Administer prochlorperazine (Compazine) 10 mg IM.

B

The nurse is evaluating the integrity of the ventrogluteal injection site. The nurse finds the site by locating the: a. Middle third of the lateral thigh b. Greater trochanter, anterior iliac spine, and iliac crest c. Anterior aspect of the upper thigh d. Acromion process and axilla

A

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.

C

The registered nurse (RN) is caring for a client with severe cardiac disease. While caring for the client, the client states to the nurse, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." The most appropriate nursing action is to: a. Tell the client that the family must agree with the request. b. Plan a client conference with the nursing staff to share the client's request. c. Tell the client that it is necessary to notify the physician of the client's request. d. Tell the client that this procedure cannot legally be refused by a client if the physician believes that it is necessary to save the client's life.

C

When assessing a client with diabetes for diabetic nephropathy, the nurse should determine if the client has: A. ketonuria. B. polyuria. C. asymptomatic proteinuria. D. increasing glycosuria.

B

When caring for a client who has been raped, which action should a nurse take first? Highest priority. No physiological answer. A. Explore legal issues and prosecution. B. Acknowledge client's anxiety and fear. C. Explore client's feelings about recovery. D. Introduce defensive tactics.

B

When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. What is the nurse's primary intervention? a. Placing the client in a high Fowler's position and administering intravenous fluids b. Deflating the blood pressure cuff and administer oxygen c. Documenting the finding as the only action d. Notifying the health care provider

A (Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer options are not applicable to hypokalemia.)

Which clinical manifestation or condition indicates that treatment for hypokalemia is effective? a. The client reports having a bowel movement daily. b. The client has gained 2 pounds during the past week. c. The client's electrocardiogram (ECG) shows an inverted T wave. d. The client's fasting blood glucose level is 106 mg/dL.

Ad

Which clinical manifestations should a nurse recognize as being related to the "negative" (what are negative symptoms? symptoms associated with a schizophrenic client? Select all that apply. Negative Symptoms: Delusions Conceptual disorganization Blunted affect Emotional withdrawal Poor rapport Passive/apathetic social withdrawal Difficulty in abstract thinking Lack of spontaneity and flow of conversation Stereotyped thinking A. Brief, empty responses. B. Clang associations. C. Inappropriate sexual behaviors. D. Poor eye contact. E. Somatic delusions.

Ace

Which interventions will help decrease the risk of aspiration during feeding? (Select all that apply.) a. Have the client sit upright in a chair. b. Give liquids at the end of the meal. c. Place food in the strong side of the mouth. d. Provide thin foods to make it easier to swallow. e. Feed the client slowly, allowing time for the client to chew and swallow.

D

Which nursing assessments should indicate to a nurse that a newly admitted client is in amphetamine withdrawal? A. Apprehension, tremors, and psychosis-delirium.--etoh B. Insomnia, anxiety, and loss of appetite. benzos C. Vomiting, tremors, and diaphoresis. Narcs D. Depression, lack of energy, and somnolence.

D

Which option is an example of a primary preventive measure? A. Having an annual physical examination B. Participating in a cardiac rehabilitation program C. Practicing monthly breast self-examination D. Avoiding overexposure to the sun

Positive

____ Symptoms: Hallucinations Excitement Grandiosity Suspiciousness Hostility

C

3. How does antibiotic therapy increase the risk for infection? a. IV antibiotics contain high concentrations of glucose, an ideal medium for bacterial growth. b. Associated diarrhea causes intestinal ulcerations to form, creating a new portal of entry. c. Antibiotic therapy also kills off normal flora, which provide protection from infection. d. The resulting dead bacteria provide a rich culture medium for viruses.

D

6. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? a. Obtain the pre-transfusion hemoglobin level. b. Prime the tubing and prepare a blood pump set-up. c. Monitor vital signs q15 minutes for the first hour. d. Ensure the accuracy of the blood type match.

B

A client whispers, "The spiders are coming out of the vents; we need to move." Which response by a nurse demonstrates the therapeutic technique of focusing on reality? A. "I didn't understand you. Can you repeat that?" B. "I don't see any spiders." We assume that spiders are not, in fact, coming out of the vents. C. "What did you see?" D. "That must be frightening to think that."

B

A client who is being treated with lithium carbonate for manic depression develops diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the healthcare provider immediately and prepare for administration of an antidote. b. Notify the healthcare provider of the symptoms prior to the next administration of the drug. c. Record the symptoms as normal side effects and continue administration of the prescribed dosage. d. Hold the medication and refuse to administer additional amounts of the drug.

A (Pronestyl is a class 1A antidysrhythmic. It should be taken around the clock so that a stable blood level of the drug can be maintained, thereby decreasing the possibility of hypotension (an adverse effect) occurring because of too much of the drug circulating systemically at any time of the day. May be given with food is GI distress is a problem, but maintain around the clock dosing)

A client with a dysrhythmia is to receive procainamide (Pronestyl) in 4 divided doses over the next 24 hours. What dosing schedule is best for the nurse to implement? a. q6h. b. QID. c. AC and bedtime. d. PC and bedtime.

Ace

A client with antisocial personality disorder has been acting very manipulative. Which actions by a nurse will help to reduce the manipulative behaviors? Select all that apply. A. Develop a list of realistic goals with the client. B. Accept small tokens of appreciation as collaboration. bribery C. Maintain consistent limit setting. D. Place the client on the "problem" board to modify behaviors. Passing the buck. E. Evaluate actions, the consequences, and successes.

A

A client, who abuses alcohol, is at risk for injury during the detoxification phase of alcohol withdrawal. Which physician order for this client should the nurse question? A. Apply soft wrist restraints as needed. (can't have prn restraints) B. Bedrest with side rails up. C. Maintain IV D5 0.45% NS at 100 mL/hr. D. Baseline ECG.

C

A client, who has abused alcohol for 20 years, is admitted to a rehabilitation unit. Which laboratory values should a nurse expect to find? A. Decreased total protein and increased albumin. B. Increased blood alcohol levels and impaired reflexes. C. Increased LDH and amylase and decreased albumin. D. Decreased potassium and increased magnesium.

B

A client, who has had several verbal outbursts and is pacing around a psychiatric unit, is at risk for assaultive behavior. (assessment finding) Which verbal response by a nurse is most appropriate? (according to whom? To what end?) (intervention—what is the goal of this intervention. Safety for client and others—this is like a severe communicable disease—same principle) A. "Do not get agitated; everything is safe here." B. "Please take a time-out in your room." (Do first) C. "If you don't follow the rules, you will be put in seclusion." D. "Let me take your blood pressure. I think you are having a lot of anxiety."

B

A primary prevention measure that should be implemented by a nurse when working with clients who are at risk for elder abuse is: Four poor answers. Which goes to the stem of the question? While this is passing the buck, it is the right answer. A. Reporting a case to law enforcement officials. B. Referring caregivers to community resources. C. Offering counseling to the victim. Primary prevention—nothing has happened yet. D. Providing the elder with hotline numbers.

B

A psychiatric nurse is assigned to care for multiple clients. Which client should the nurse assess first? (Highest acuity according to Maslow.) A. The client with auditory hallucinations, who is responding to the voices with laughter. B. The client with hallucinations, who has increased blood pressure and heart rate. Circulation. C. The client with suicidal ideations, who has a nonlethal plan. D. The client with superficial self-inflicted wounds to arms.

B

A registered nurse (RN) can best demonstrate empathy by: A. Revealing personal experiences with similar issues. Sympathy. B. Conveying genuine understanding of the client's problems. C. Identifying behavioral problems. Assessment. D. Advising the client about better communication techniques. Not empathy.

CDE

An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is likely to help the child cope with fear and separation? Select all that apply. A. Tell the child that he must act like a "big boy" while he's in the facility. Belittling. B. Ask the physician to explain to the child why he needs to stay in the health care facility. Passing the buck. C. Maintain as many bedtime rituals as possible while the child remains in the facility. Promotes Security D. Encourage parents to bring a favorite toy/stuffed animal from home for the child. Promotes security. E. Have the parents stay with the child and participate in his care. Promotes security.

D

An adolescent client is diagnosed with anorexia nervosa and discloses an incestuous relationship. Which is a nurse's most therapeutic response? (according to whom?) A. "Tell me more about what happened when you were younger." Could answer yes or no. B. "You will be okay, just keep on talking." False Reassurance. C. "What kind of comfort food do you want tonight?" Changes the subject. D. "Can you tell me how you feel about what happened?"

C

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? 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 rounds 30 minutes before the fall occurred.

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.

B

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly a. Is to be expected, and progresses with age. b. Often follows relocation to new surroundings. c. Is a result of irreversible brain pathology. d. Can be prevented with adequate sleep.

D

The client tells the nurse that his arm cast feels really tight and his fingers are puffy. What is the nurse's best response? a. "Elevate your arm on two pillows and apply ice to the cast." b. "Continue to take ibuprofen (Motrin) until the swelling subsides." c. "It is normal for a new cast to feel a little tight for the first few days." d. "Please come to clinic today to have your arm checked by the physician."

D (Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency the client may not be able to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but tin this case it is not an emergency. Agency policies regarding informed consent should always be followed.)

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse should take which action as the priority? a. Obtain a court order for the surgery. b. Send the client to surgery without the consent form being signed. c. Have the hospital chaplain sign the informed consent immediately. d. Obtain a telephone consent from the family member witnessed by two persons.

D (The Z-track method is used to minimize local skin irritation by sealing the medication in muscle tissue. The Z-track method does not provide faster absorption of the medication. The Z-track method does not reduce discomfort from the needle. The Z-track method does not provide a more even absorption of the drug.)

The nurse administers the intramuscular medication of iron by the Z-track method. The medication was administered by this method to: a. Provide faster absorption of the medication b. Reduce discomfort from the needle c. Provide more even absorption of the drug d. Prevent the drug from irritating sensitive tissue

A (enteric can't be crushed)

The nurse is administering a sustained-release capsule to a new client. The client insists that he cannot swallow pills. The best course of action for the nurse is to: a. Ask the physician to change the order. b. Crush the pill with a mortar and pestle. c. Hide the capsule in a piece of solid food. d. Open the capsule and sprinkle it over pudding nurse is caring for a client experiencing dysphagia.

Ade

The nurse is assessing a client who has a chronic mental illness. What early signs of relapse should the nurse monitor for? Select all that apply. A. increase in social isolation and withdrawal B. obvious delusions and hallucinations late sign C. suicidal or homicidal threats late sign D. decrease in sleep and self-care E. more fears and suspiciousness

D

The nurse is caring for 4 clients on an orthopedic floor: 2 clients with total hip replacements, one client with total knee replacement, and one client with a fractured femur who is in skeletal traction. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Adjust the setting on the continuous passive motion machine (CPM). b. Clean the skeletal traction insertion sites while performing a.m. care. c. Assist the client to ambulate for the first time after surgery. d. Change the linens for the client with skeletal traction.

B

The nurse is caring for a client who has been brought to the emergency room with upper GI bleeding. The client is unconscious and requires lavage to stop the bleeding. Which is the nurse's priority action? a. Preparing to intubate the client with an endotracheal tube b. Inserting a 20-gauge IV and starting a normal saline IV infusion c. Obtaining a 14 French nasogastric tube and iced normal saline for the procedure d. Setting up the suction unit with collection canister and medium intermittent suction

D (Motrin and other NSAIDs can cause gastritis, even if symptoms are not yet apparent. Stress, travel, and spicy foods do not increase the risk for gastritis.)

The nurse is caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion? a. The client is lactose-intolerant and cannot drink milk. b. The client recently traveled to Mexico and South America. c. The client works at least 60 hours per week in a stressful job. d. The client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.

B (Sudden, sharp mid-epigastric pain is indicative of perforation, which is a surgical emergency. Pain medication should not be administered just now because the surgeon will need to assess the client's abdomen, and the client will need to sign an operative permit. The client may assume the knee-chest position in an attempt to relieve pain. The provider may order placement of an NG tube, but this would not take priority over getting the client ready for surgery.)

The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? a. Placing the client in a knee-chest position b. Preparing the client for emergency surgery c. Inserting a nasogastric tube to low intermittent suction d. Administering morphine 2 mg IV as ordered by the physician

B (-Sodium bicarbonate can cause fluid retention and edema, which can be dangerous for clients with congestive heart failure. The physician should be notified right away so that an alternative antacid can be prescribed)

The nurse is caring for a client with congestive heart failure and chronic gastritis. The client tells the nurse that he takes 2 teaspoons of sodium bicarbonate every night before bed to prevent heartburn. Which is the nurse's best response? a. "You should let the doctor know right away if you develop stomach cramps." b. "I will let your doctor know so that a safer antacid can be prescribed for you." c. "Do not take the sodium bicarbonate with milk, because it can cause kidney stones." d. "Make sure that you mix the sodium bicarbonate with at least 8 ounces of water."

D (Suctioning shouldn't be continued longer than 10-15 seconds, since the client's oxygenation is compromised during this time.)

The nurse is 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.

B

The nurse is teaching a client with cancer about opioid management for intractable pain and tolerance related side effects. The nurse should prepare the client for which side effect that is most likely to persist during long-term use of opioids? a. Sedation. b. Constipation. c. Urinary retention. d. Respiratory depression.

C

17. A registered nurse (RN) who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The most appropriate initial action by the RN is which of the following? a. Call security. b. Call the police. c. Call the nursing supervisor. d. Lock the co-worker in the medication room until help is obtained.

A?

8) Which intervention would most likely prevent nausea in a client receiving cisplatin chemotherapy? A. Administering trimethobenzamide prn nausea. B. Administering dexamethasone and ondansetron prior to chemotherapy. C. Serving all food warm or hot. D. Keeping client NPO 24 hours before chemotherapy.

C

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? a. Give small, frequent feedings of fluids. b. Accurately chart observations regarding breath sounds. c. Have a bulb syringe readily available to remove secretions. d. Encourage older siblings to visit.

A

A 35-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client? To achieve what? A. She should eat a low-fat diet to further decrease her risk of breast cancer. B. When she begins having yearly mammograms, breast self-examinations will no longer be necessary. Rule out. Assessment is good. C. She should have had a baseline mammogram before age 30. You know this stuff. D. She should perform breast self-examination during the first 5 days of each menstrual cycle.

B (The systemic effects of CHF Clients with congestive heart failure have impaired circulation, which impairs medication delivery to the intended site of action. Therefore the efficacy of medications in these clients is delayed or altered. The other options reflect possible barriers, but they are not as directly responsible as is the heart's functional capacity)

A 78-year-old client with congestive heart failure (CHF) is reporting vascular pain in his lower legs and requests his oral narcotic analgesic. The nurse recognizes that the client's pain relief will be negatively affected primarily because of: a. The client's age b. The systemic effects of CHF c. The route of administration d. The status of the peripheral vessels

A (The normal erythrocyte sedimentation rate for women is 20 mm/hr. The client's ESR is 35 mm/hr, indicating the presence of the inflammatory process. The normal WBC count is 5000-10,000/mm3. The client is within normal limits at 8000/mm3. The normal neutrophil count is 55-70%. The client is within normal limits at 65%. The normal iron level is 60-90 g/100 mL. The client is within normal limits at 75 g/100 mL.)

A female client has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. Upon reviewing the results, the nurse will report which of the following findings to the physician, which is abnormal? a. Erythrocyte sedimentation rate (ESR) 35 mm/hr b. White blood cell (WBC) count 8000/mm3 c. Neutrophils 65% d. Iron 75 g/100 mL

A

The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? a. 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os. b. 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. c. 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP. d. 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.

D

The client is prescribed risperidone (Risperdal) at discharge for treatment of bipolar disorder. A nurse should recognize that more teaching is needed when the client states: A. "I will call the physician if I have unusual movements." correct B. "I will not stop the medication when my voices have gone away." correct C. "I will pay close attention to my weight increases." correct D. "I will have my liver panel drawn every month."

A (Opiates, particularly morphine, increase the release of vasopressin (antidiuretic hormone), thereby decreasing urine output.)

The client is receiving 300 mg of morphine daily for severe pain. Which is the nurse's priority intervention? a. Measuring intake and output b. Taking the client's temperature every 4 hours c. Auscultating bowel sounds in all four quadrants d. Asking the client to rate pain on a visual analogue scale

B (The client's symptoms are consistent with the development of pulmonary embolism caused by leg immobility in the long cast. The nurse should check the client's pulse oximetry reading and provide oxygen to keep saturations greater than 92%. Auscultating lung fields, checking blood glucose level, or deep breathing will not assist this client. The correct answer is: Administer oxygen to keep saturations greater than 92%.)

The client who had a long leg cast applied last week tells the nurse that he just can't seem to catch his breath and feels a bit lightheaded. Which is the priority action of the nurse? a. Listening to the client's lungs and checking the client's blood glucose level b. Giving the client 2 L of oxygen via nasal cannula and checking vital signs c. Check the client's pulse oximetry and arranging emergency transfer to the hospital d. Reassuring the client that it takes much more effort to move with a long leg cast