Exam 2, Fundz 2 Questions

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A nurse is teaching the daughter of an older adult patient how to instill eye drops in the patient's right eye. Which of the following statements indicates that the daughter has understood the directions? "I will have my mother look down while dropping the medication into her eye." "I will instruct my mother to tightly close her eye for 30 to 60 seconds after the medication has been given." "I should apply the medication using a thin stream from the inner canthus to the outer canthus." "I will pull down her lower eyelid and drop the medication inside."

"I will pull down her lower eyelid and drop the medication inside."

A patient is to receive 12.5 mg of prednisone (Deltasone) by mouth daily. The medication is available in 5 mg tablets. How many tablets should the nurse administer for each dose?

2.5 Tablets

For many clients, health promotion requires nursing assessment of and implementation of changes in A. lifestyle. B. spiritual beliefs. C. socioeconomic status. D. culture.

Which population should the nurse assigned to care for pediatric clients recognize as having the highest risk of hospitalization due to RSV? A) Alaskan Native infants B) African American infants C) Native American infants D) Asian American infants

A) Alaskan Native infants

The nurse is evaluating care provided to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which observation would indicate that care provided to this client has been effective? A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading. B) Client needs assistance with morning care and meals due to shortness of breath. C) Client states family members are discussing admission to a nursing home for continuing care. D) Client leaves hospital unit to smoke outside four times a day.

A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.

Which prevention strategies would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV) bronchiolitis? Select all that apply. A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. C) Encourage physical activity and play. D) Consider alternatives to sending the child to daycare. E) Ensure an adequate nutritional intake.

A) Do not smoke, and avoid all secondhand smoke around the child. B) Practice frequent hand washing. D) Consider alternatives to sending the child to daycare.

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply. A) Elevate head of the bed B) Administer a high rate of oxygen by nasal cannula C) Prepare for a chest tube insertion D) Administer prescribed antihypertensive medications E) Administer intravenous caffeine per order

A) Elevate head of the bed C) Prepare for a chest tube insertion

Oxygen therapy is prescribed for a patient who is brought to an emergency department in the early stages of hypoxia. When assessing this patient, the nurse should expect to find which of the following clinical indicators? A) Elevated blood pressure B) Decreased respiratory rate C) Cyanosis D) Peripheral edema

A) Elevated blood pressure

The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client? A) Inhaled short-acting beta-agonists B) Oral corticosteroids C) Inhaled long-acting beta-agonists D) Oral anticholinergics

A) Inhaled short-acting beta-agonists

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO2 of 82, PaCO2 of 49, HCO3 of 26, and pH of 7.31. Which assessment by the nurse is correct? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

A) Respiratory acidosis

The nurse is collecting a health history for a 12-month-old child. The child lives in a home where both parents smoke, and the child has had respiratory syncytial virus twice since birth. The child's older sister was recently diagnosed with asthma. The nurse understands that this child's risk of developing asthma later in life is A) above average. B) average. C) below average. D) well below average.

A) above average.

A 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse assess? A. Stress B. Family History C. Sex D. Age

A. Stress Rationale: There are numerous risk factors for development of hypertension. Certain risk factors that cannot be modified include age, sex, family history, and ethnicity. Men, African Americans, and those over 65 have an increased risk of developing hypertension, as well as those with a significant family history of heart disease. Modifiable risk factors include lifestyle choices, such as smoking, stress, sedentary lifestyle, and high-fat diet. The nurse should discuss lifestyle management with clients who are at risk for hypertension.

A nurse must reconstitute a powdered medication. Which action should the nurse implement? A. Keep the needle below the initial fluid level as the rest of the fluid is injected. B. Instill the solvent that is consistent with the manufacturer's directions. C. Score the neck of the ampule before breaking it. D. Shake the vial to dissolve the powder.

Answer: B A. This will create excessive bubbles that can interfere with complete reconstitution or result in bubbles being drawn into the syringe. Both occurrences can result in an inaccurate dose. B. Compatibility is necessary so that a compound or precipitate that is harmful to a client does not result. C. Reconstitution occurs in a vial (a closed system), not an ampule (an open system). D. Shaking the vial will create excessive bubbles. The vial should be rotated between the hands to facilitate reconstitution.

1) What will the nurse most likely assess in a client with right heart failure? A) Leg cramps B) Indigestion C) Reduced circulation to the pulmonary structures D) Reduced urine output

Answer: C

A newly admitted client is ordered morphine 6-10 mg IM q 3 hours prn for severe pain. The client rates the pain 10/10. What dose should be the nurse administer? A. 10 mg B. 8 mg C. 7 mg D. 6 mg

Answer: D Rationale: Always start off with the smaller dose

Which information is not listed in the medication administration record (MAR)? A. Date of medication administration. B. Route of drug administration. C. Dose of medication. D. Drug classification.

Answer: D Rationale: The information on the MAR includes (option 1) the date the medication is to be administered, (option 2) the route of administration, and (option 3) the dose to be administered. It does not include the actual classification of the medication(s) ordered.

Which oxygen delivery method should the nurse know may be set to deliver an exact FiO2 of 45%? A. Simple face mask B. Nasal cannula C. Nonrebreather mask D. Venturi mask

Answer: D Rationale: Venturi masks are set with a specific oxygen flow rate and specific jet adapter device. Flow rates of 24-50% may be set with the Venturi mask. The other oxygen delivery methods cannot deliver a specific flow rate.

The pathophysiologic stimulus that initiates asthma is A) bronchoconstriction. B) inflammation in the airways. C) airway edema. D) mucus secretion.

B) inflammation in the airways.

7) An older client admitted with pneumonia has a normal body temperature. What should the nurse realize as being the reason for the inconsistency in body temperature? A) The room is cold. B) The client does not have pneumonia. C) The temperature is not a valid indicator of the pathology of the illness. D) The client is losing body heat

C Older adults' temperatures may not be a valid indication of the seriousness of the pathology of a disease. Other symptoms such as confusion and restlessness may be a more accurate indicator. A decrease in temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.

An infant with respiratory syncytial virus (RSV) bronchiolitis is prescribed intubation to maintain an adequate airway. Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? A) An advanced practice nurse B) The primary healthcare provider C) A respiratory therapist D) A play therapist

C) A respiratory therapist

You have a handwritten medication order that is difficult to read. Which of the following is the most appropriate action to take to avoid an error in medication administration? -Ask another nurse to decipher the medication order -Call the medical provider for clarification of the order -Rely on your knowledge of the patient to get this order right -Inquire at the hospital pharmacy about the order

Call the medical procuder for clarification of the order

With which route of drug administration are there no barriers to absorption? -Intravenous -Intramuscular -Subcutaneous -Oral

Intravenous

Which of the following terms indicates a mediation is being given by injection? -Enteral -Sublingual -Transdermal -Parenteral

Parenteral

A nurse is preparing to insert an insulin injection into a patient. Which of the following is appropriate? -Rotate injection sites to avoid injury -Administer no more than 2 mL per injection -Use the non dominant hand to displace the subcutaneous tissue at the injection site 1-1 1/2 inches -Inject the medication after aspirating the syringe

Rotate injection sites to avoid injury

A nurse is caring for a patient who has been prescribed a fluticasone propinate (Flovent HFA) inhaler with a spacer. The patient asks the nurse why a spacer is needed with the inhaler. Which of the following responses by the nurse is correct? "By using a spacer, you can take the medication correctly without any spills." "You can inhale five or more puffs in 1 min when using a spacer." "By using a spacer, you eliminate the need for mouth rinsing after administration." "More medication is delivered to the lungs when you use a spacer."

"More medication is delivered to the lungs when you use a spacer."

A nurse is teaching a client who has a prescription for a drug that has a receptor agonist effect. Which of the following information should the nurse include in the teaching? [] "This will increase the effects of normal cellular functions" [] "this prevents cells in your body from performing certain actions" [] "this prevents hormones in your body from attaching to cell receptor sites" [] "this minimizes the risk that the medications you take will become toxic"

"This will increase the effects of normal cellular functions" Agonist drugs bind to cell receptors in the body and are targeted to a specific type of receptor. When they attach to the receptors, they perform the same action as a hormone or chemical would, increasing the effects of that hormone or chemical. For example, pharmacological insulin is administered to clients who have little to no insulin to mimic insulin's effects in the body.

A nurse is teaching a client about the adverse effects of digoxin. which of the following statements should the nurse include in the teaching? [] "adverse effects are the intended effects of the medication." [] "adverse effects indicate a severe allergy to the medication." [] "decrease your medication dose if adverse effects occur." [] "contact your provider if adverse effects occur."

"contact your provider if adverse effects occur."

The proper needle length when giving an intramuscular injection in the ventrogluteal area to an average-sized adult is? -1/2 in -1 in -1 1/2 in -2 in

1 1/2 in

A patient is to receive 30 mg of ketorolac (toradol) every 6hrs for 48 hrs. The medication is available in 60 mg/2 mL vial. How many mL should the nurse administer for each dose?

1 mL

A nurse is caring for a 50-year-old client performing aerobic exercise in the cardiac rehabilitation office. The nurse calculates the client's target heart rate as ______-_____ beats per minute(BPM).

102-145

A patient drinks 8 oz of water. Which of the following is a correct conversion of the patients intake? -1 pint -4 tablespoons -2 cups -240 mL

240 mL

A school nurse is reviewing the physical activity for adolescent high school students. Which student has met the outcome for physical activity set by the Centers for Disease Control and Prevention (CDC)? A. A 17-year-old who alternates aerobic activities for 60 minutes daily and lifts weights 2 times per week B. An 18-year-old who speed-walks 60 minutes once per week C. A 15-year-old who runs at a fast pace for 20 minutes 2 times per week D. A 16-year-old who lifts moderately heavy weights for 15 minutes 3 times per week

A young school-age child is seen in a pediatric clinic for a well-child checkup. The parent tells the nurse that they live in the country and use well water. Based on this data, which statement by the nurse is the priority when conducting client teaching? A. "Your child will need to be placed on a fluoride supplement because your primary water source is from a well." B. "Your child will need to use a teeth whitener in the future because well water is your primary water source." C. "It will be very important that your child does not eat sugary foods because you drink well water." D. "I will recommend some mouthwashes that are appropriate for clients who drink well water."

The nurse receives a referral for a patient for occupational therapy. The patient's family asks, "Why does our mother need this referral?" Which response by the nurse is appropriate? A. "Your mother needs assistance in completing daily tasks so she can be more independent." B. "Your mother could benefit from exercise to become more mobile." C. "Your mother is having difficulty swallowing." D. "Your mother needs relaxation and distraction."

A Occupational therapists help a patient maintain and optimize skills that are necessary to complete activities of daily living (ADLs). They can also recommend modifications to the patient's home environment to allow the patient to become more independent. Physical therapists help patients to preserve or regain mobility. Speech therapy deals with speech and swallowing issues. Music therapy is used for psychological issues.

Which of the following patient's is exhibiting drug tolerance? -A patient continues to take a medication despite harmful effects -A patient requires an increased dose of a medication to achieve continued therapeutic benefit -A patient exhibits signs of withdrawal after a medication is discontinued -A patient develops an intense craving for a drug

A patient requires an increased dose of a medication to achieve continued therapeutic benefit

The nurse is planning care for the parents of an infant who died as the result of sudden infant death syndrome. Which collaborative interventions does the nurse plan for when providing care to these parents? Select all that apply. A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain E) A respiratory therapist referral

A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain

When a nurse performs or observes nursing practices that are not safe, the nurse has a responsibility to report those actions. This principle ties the concept of safety to what other nursing concept? A) Accountability B) Advocacy C) Assessment D) Clinical Decision Making

A) Accountability Nurses are accountable for their actions, so all unsafe nursing practices should be reported and addressed. This principle does not reflect advocacy, assessment, or clinical decision making.

What is one genetic cause of COPD? A) Alpha-1 antitrypsin deficiency B) A defect in the CFTR gene C) A mutation in the superoxide dismutase 1 gene D) Mutations in the human leukocyte antigen

A) Alpha-1 antitrypsin deficiency

The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which group of infants? A) American Indians B) Caucasians C) Asians D) Hispanics

A) American Indians

A) Elevate head of the bed C) Prepare for a chest tube insertion The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed because of the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to meet nutritional needs? Select all that apply. A) Encourage a diet high in protein and fats. B) Keep snacks to a minimum. C) Provide frequent small meals with between-meal supplements. D) Encourage carbohydrate-rich foods to provide needed calories for energy. E) Suggest the client eat three meals per day to maintain energy needs.

A) Encourage a diet high in protein and fats. C) Provide frequent small meals with between-meal supplements.

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV). What should the nurse stress as the best way to prevent RSV? A) Hand washing B) Monitoring temperature C) Administering antibiotics D) Limiting fluid intake

A) Hand washing

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A) Increased CO2 B) Vasoconstriction C) Decreased O2 D) Decreased intracranial pressure (ICP) E) Increased pulse rate

A) Increased CO2 C) Decreased O2 E) Increased pulse rate

A) Increased CO2 C) Decreased O2 E) Increased pulse rate Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO2). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation.

A) Inhaled short-acting beta-agonists The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which variables should the nurse highlight as contributing to increased risk of SIDS? Select all that apply. A) Prone sleeping B) Side sleeping C) Loose bedding D) Bed sharing E) Supine sleeping

A) Prone sleeping B) Side sleeping C) Loose bedding D) Bed sharing

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). When planning care for this client, which interventions are appropriate to enhance the client's breathing pattern? Select all that apply. A) Provide adequate rest periods. B) Assist with activities of daily living (ADLs). C) Educate on relaxation techniques. D) Educate on pursed-lip breathing. E) Administer a cough suppressant.

A) Provide adequate rest periods. B) Assist with activities of daily living (ADLs). C) Educate on relaxation techniques. D) Educate on pursed-lip breathing.

What is the best way nurses can help clients reduce the risk of COPD? A) Providing smoking cessation resources B) Encouraging clients to receive vaccinations C) Referring clients to a nutritionist D) Providing references to local fitness facilities

A) Providing smoking cessation resources

When assessing the risk of a newborn for sudden infant death syndrome (SIDS), which are risk factors that the nurse should consider? Select all that apply. A) Race B) Gender C) Father's age D) Age E) Eye color

A) Race B) Gender D) Age

The nurse working in the emergency department (ED) is assessing an infant client. Which findings does the nurse anticipate in a child diagnosed with respiratory syncytial virus (RSV)? Select all that apply. A) Rhinorrhea B) Irritability C) Grunting D) Bradypnea E) Tachypnea

A) Rhinorrhea B) Irritability C) Grunting E) Tachypnea

The nurse is planning care for a baby born to a mother who smoked during the pregnancy. The mother states that she believes in bed sharing. Which nursing diagnosis would be appropriate for this baby? A) Risk for Sudden Infant Death Syndrome (SIDS) B) Readiness for Enhanced Parenting C) Anxiety D) Deficient Knowledge

A) Risk for Sudden Infant Death Syndrome (SIDS)

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply. A) Sepsis B) Viral pneumonia C) Drug overdose D) Near drowning in saltwater E) Fractured humerus

A) Sepsis B) Viral pneumonia C) Drug overdose D) Near drowning in saltwater

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma. Which assessment data indicate impending respiratory failure and the need for immediate intervention? Select all that apply. A) Shallow respirations B) Slightly diminished breath sounds C) Decreased wheezing D) Increased crackles E) Increased respiratory rate

A) Shallow respirations C) Decreased wheezing

Which of the following triggers can stimulate an acute asthma attack? Select all that apply. A) Stress B) Animal dander C) Loud noises D) Exercise E) Bright lights

A) Stress B) Animal dander D) Exercise

The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent) for asthma. Which should be included in this client's teaching? Select all that apply. A) Take no more than the prescribed number of doses each day. B) Rinse the mouth after taking this medication. C) Take on an empty stomach. D) Take with meals or a full glass of water. E) Use hard candy or drink extra fluids to help with a dry mouth.

A) Take no more than the prescribed number of doses each day. E) Use hard candy or drink extra fluids to help with a dry mouth.

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which intervention is appropriate to decrease an infant's risk for SIDS? A) Using firm bedding B) Ensuring the room temperature is at least 80°F at all times C) Recommending bed sharing D) Placing the infant in a prone position for sleeping

A) Using firm bedding

The ion that cannot be regulated properly in clients with cystic fibrosis is A) chloride. B) sodium. C) calcium. D) potassium.

A) chloride.

Vaccinations can help promote healthy oxygenation by A) reducing the transmission of preventable diseases. B) increasing the exchange of oxygen for carbon dioxide in the lungs. C) promoting adequate blood circulation to organs and tissues. D) preventing all respiratory infections.

A) reducing the transmission of preventable diseases.

A) reducing the transmission of preventable diseases. Vaccinations help decrease the transmission of preventable diseases, many of which are spread by respiratory secretions. Many of these diseases also affect the respiratory system and can alter oxygenation. Vaccinations do not directly increase the exchange of oxygen for carbon dioxide in the lungs, nor do they promote adequate blood circulation. Vaccinations can prevent some respiratory infections, but not all respiratory infections, and they can also prevent some nonrespiratory infections.

A client is diagnosed with several fractures of the axial skeleton. Which bone fracture should the nurse anticipate providing care for in this client? (Select all that apply.) A. Vertebra B. Ribs C. Lower leg D. Arm E. Femur

A, B Rationale: The axial skeleton is made up of the ribs, sternum, vertebral column, and skull. The appendicular skeleton is made up of the pectoral girdles, upper limbs, pelvic girdle, and lower limbs.

The nurse is developing a plan of care for a client experiencing an alteration in mobility. Which objective is most appropriate for the nurse to include? (Select all that apply.) A. Prevent injury B. Promote education C. Promote healthy relationships D. Promote comfort E. Recommend immunizations

A, B, D Rationale: Independent nursing interventions for the client with an alteration in mobility focus on promoting education and comfort as well as preventing injury. Although promoting healthy relationships and recommending immunizations may be important for all clients, these nursing interventions are not specifically important to clients with alterations in mobility.

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? A. "Flush the tube before and after each medication." B. "Mix your medications with your enteral feeding." C. "Push tablets through the tube slowly." D. "Mix all the crushed medications prior to dissolving them in water."

A. "Flush the tube before and after each medication." Rationale: A. Correct: The client should flush the tubing before and after each medication with 15 to 30 mL water to prevent clogging of the tube. B. To maximize the therapeutic effect of a medication, the client should not mix medications with enteral formula. In addition, if the client does not receive the entire feeding, he does not receive the entire medication. This can also delay the client receiving the medication. C. The client should not administer tablets or undissolved medications through a jejunostomy tube because they can clog the tube. D. The client should self-administer each medication separately.

A nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the group understands how to implement medication therapy? (Select all that apply.) A. "I will observe for side effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a medication if I believe it is unsafe."

A. "I will observe for side effects."; B. "I will monitor for therapeutic effects."; E. "I will refuse to give a medication if I believe it is unsafe." Rationale: A. Correct: The nurse is responsible for observing for side effects. This is within a nurse's scope of practice. B. Correct: The nurse is responsible for monitoring therapeutic effects. This is within a nurse's scope of practice. C. The provider is responsible for prescribing the appropriate dose. This is outside of the nurse's scope of practice. D. The provider is responsible for changing the dose if adverse effects occur. This is outside of the nurse's scope of practice. E. Correct: The nurse is responsible for identifying when a medication could harm a client. It is within the nurse's scope of practice to refuse to administer the medication and contact the provider.

A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? (Select all that apply). A. 0905 B. 0825 C. 1000 D. 0840 E. 0935

A. 0905; D. 0840 Rationale: A. Correct: The nurse should administer medications within 30 min of the time it is due. 0905 is within 30 min of the time the medication is due. B. 0825 is not within 30 min of the time the medication is due. C. 1000 is not within 30 min of the time the medication is due. D. Correct: 0840 is within 30 min of the time the medication is due. E. 0935 is not within 30 min of the time the medication is due.

The nurse is obtaining an apical pulse in an infant. What is the best site for the nurse to place the stethoscope? A. At the left nipple at the 4th intercostal space B. At the right nipple just above the 3rd intercostal space C. In the left mid-axillary area at the 4th intercostal space D. Just below the clavicle between the 1st and 2nd intercostal space

A. At the left nipple at the 4th intercostal space Rationale: Heart sounds in an infant can be best auscultated around the left nipple at the 4th intercostal space. This is the loudest sound reference in infants. In adults, the sound is best heard at the apex (base) of the heart between the 4th and 5th intercostal spaces just to the left of the sternum.

List the six rights of medication administration. Describe how you would maintain these rights in the medication administration process.

A. First of all, I am going to check my medication three times: when I take it out of the ADS, when I am preparing the medication, and in the patient's room. B. Right drug - do the three checks C. Right patient - check armband against MAR, using name and MRN D. Right route - do three checks and use appropriate devices (like oral syringe for liquids) E. Right time - check MAR and hospital policy on window of administration F. Right dose - do three checks and ensure this is a safe dose G. Right documentation - document after the med is given.

A nurse prepares an injection of morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? A. Offer to assist the client who needs the bedpan. B. Administer the injection the other nurse prepared. C. Prepare another syringe and administer the injection. D. tell the client who needs the bedpan she will have to wait for her nurse.

A. Offer to assist the client who needs the bedpan. Rationale: A. Correct: The second nurse should offer to assist the client who needs the bedpan. This will allow the nurse who prepared the injection to administer it. B. A nurse should only administer medications that she prepared. C. Preparing another syringe will delay the administration of the pain medication. D. Telling the client to wait is not an acceptable option for a client who needs a bedpan .

Which independent nursing intervention would be most beneficial for a client who experiences extreme shortness of breath with activity? A. Promoting relaxation techniques B. Administering increased oxygen as needed with activity C. Elevating lower extremities to prevent edema D. Dietary teaching

A. Promoting relaxation techniques Rationale: Clients who have decreased perfusion and become air-hungry as they exert themselves may develop extreme anxiety. The nurse can assist with promoting relaxation and reassurance to alleviate anxiety and increase comfort. Dietary teaching should be part of teaching, but it is not a priority over managing anxiety with shortness of breath. Administering increased dosages of oxygen is a collaborative intervention that requires a healthcare prescriber's order. Elevating lower extremities can help manage edema, but it is not priority over promoting relaxation and alleviating anxiety.

A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication.

A. Take sips of water frequently; B. Wear sunglasses when outdoors in sunlight; E. Urinate prior to taking the medication Rationale: A. Correct: Taking sips of water frequently will help relieve the anticholinergic effect of dry mouth. B. Correct: Wearing sunglasses will help relieve the anticholinergic effect of photophobia. C. Anticholinergic effects do not increase the client's risk for bleeding. Constipation is an example of an anticholinergic effect. D. Taking the medication with an antacid will not decrease anticholinergic effects. Constipation is an example of an anticholinergic effect. E. Correct: Urinating prior to taking the medication will help relieve the anticholinergic effect of urinary retention.

Order types: List the order type for the following orders and the time frame it must be administered. A. Ancef 1 gm IV OCTOR (on call to the operating room) B. Dilaudid 2mg IV q 4-6 hours prn pain C. Tetracycline 250mg po q 6 hours.

A. this is a one-time order, to be given prior to going into the OR. B. prn order type can be given every 4 hours. Cannot be given before the 4 hour time frame. C. standing order. Since this is an antibiotic it must be given every 6 hours around the clock 6,12,18,24 (or whatever the hospital policy is for every 6 hours but must be 6 hours apart).

An uncommon, unexpected, or individual drug response though to result from genetic predisposition is called -An idiosyncratic effect -An allergic reaction -A toxic effect -A synergistic effect

An idiosyncratic effect

The nurse assessing a client suspects a right pneumothorax. Which finding supports the nurse's suspicion? A. Asymmetry of the chest expansion B. Decreased expansion on the left side of the chest C. O2 saturation of 94% D. Right tracheal shift

Answer: A Rationale: A right pneumothorax would cause asymmetry of the chest expansion and decreased expansion on the right side. Tracheal deviation would occur with a tension pneumothorax to the opposite side. An O2 saturation of 94% does not suggest a pneumothorax.

1) A client with angina complains that the pain is prolonged and severe, and occurs at the same time each day while at rest. There are no precipitating factors to the pain. How should the nurse describe this type of angina pain? A) Non-anginal pain B) Atypical angina (Prinzmetal angina) C) Unstable angina D) Stable angina

Answer: B

7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.

Answer: B

A nurse is assessing a client with a respiratory problem. Which clinical manifestation is reflective of an early response to hypoxia that requires a nursing intervention? Select all that apply. A. Dysrhythmias B. Restlessness C. Irritability D. Cyanosis E. Apnea

Answer: B, C A. A dysrhythmia, a heart rate with an irregular rhythm, can occur with hypoxia but it is a late response. B. Hypoxia is insufficient oxygen anywhere in the body. An early sign of hypoxia is restlessness, which is caused by impaired cerebral perfusion of oxygen. C. Irritability is an early sign of hypoxia caused by impaired cerebral perfusion of oxygen. D. Cyanosis, a bluish discoloration of the skin and mucous membranes caused by reduced oxygen in the blood, is a late sign of hypoxia. E. Apnea, a complete absence of respirations, is the cause of, not a response to, hypoxia.

The nurse is caring for a client with an alteration in oxygenation. Which independent action should the nurse perform? (Select all that apply.) A. Prescribe oxygen therapy. B. Suction the upper airway. C. Order a diet high in iron. D. Teach about smoking cessation. E. Place the client in high Fowler position.

Answer: B, D, E Rationale: Independent interventions are those the nurse can implement without an order or prescription. Teaching about smoking cessation, placing a client in high Fowler position, and suctioning the upper airway are all interventions the nurse can perform independently. Ordering a diet high in iron and prescribing oxygen therapy are outside the scope of nursing practice.

The primary health-care provider prescribes a troche. In which part of the body should the nurse administer the troche? A. Ear B. Eye C. Mouth D. Rectum

Answer: C A. Medications in the form of a solution are instilled into the ear. B. Ophthalmic medications in the form of a solution or an ointment are administered in the eye. C. A troche, a lozengelike tablet, dissolves slowly in the mouth in the buccal cavity to provide a localized effect. D. Medications in the form of suppositories are inserted through the anus into the rectum.

The nurse is prepared to give a stat medication to a client when another client goes into cardiac arrest. What action by the nurse would be most appropriate? A. Give the first client their stat medication then attend to the client in cardiac arrest B. Quickly drop off the medication in the room and run to the code C. Go to the code and administer the medication later

Answer: C Rationale: Priorities, need I say more?

A client states, "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." Which is the best response by the nurse? A. "I'm sure your wife will be willing to make this sacrifice in exchange for you well-being." B. "The surgeons are getting great results with nerve-sparing surgery today." C. "Your wife may not put as much emphasis on sex as you think." D. "Let's talk about how you feel about this surgery."

Answer: D Rationale: A. This response is false reassurance. Only the wife can make this statement. B. Although a true statement, this response negates the client's concerns and cuts off communication. C. This may or may not be a true statement. Only the wife can make this statement. D. The client may be using projection to cope with the potential for impotence. This response indicates that it is acceptable to talk about sexuality and invites the client to express concerns.

A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse? A. "Everyone will remember her because she was so cute. She was one of our favorites." B. "As hard as this is, it is probably for the best because she was in a lot of pain." C. "She put up the good fight, but not she is out of paid and in heaven. D. "It must be hard to deal with such a precious loss."

Answer: D Rationale: A. This response is not therapeutic because it focuses on the nurse rather than on the mother. B. The first part of this response minimizes the loss. The second part of the response focuses on the pain experienced by the child, which may increase the mother's grief. C. This response minimizes the loss and focuses on the pain experienced by the child, which may increase the mother's grief. Also, the mother may not believe in heaven. D. The nurse's response is empathetic. The response focuses on the feelings surrounding the loss and provides an opportunity for the mother to express feelings.

A client is going to surgery. Which medications should be given? A. All po and IV medications due B. None of the medications C. Only IV medications D. IV medications and po pre-operative medications

Answer: D Rationale: since the client is NPO before surgery typically po medications are not given unless the medication will help the client in surgery. Typically, most cardiac drugs are given before going to the operating room (especially beta blockers). Blood thinners are almost ALWAYS held since this would be the client at risk for bleeding. If in doubt, call the provider.

Which independent nursing intervention is a priority for a patient who is experiencing dyspnea? A. Weigh the patient daily in the morning. B. Turn the patient once per shift. C. Order oxygen 2 to 4 L/min per nasal cannula. D. Place the patient in high Fowler position.

Answer: D The priority independent intervention for a patient who is experiencing dyspnea is to place the patient in the high Fowler position to improve oxygenation. Ordering oxygen is outside the scope of nursing practice. While weighing the patient may be necessary, this is not the priority. Turning the patient is an independent nursing intervention but is not the priority for a patient with dyspnea, and it should be done more than once per shift.

A client asks the nurse how long the chest tube will remain in place. Which response by the nurse is best? A. 2 days B. 1 week C. 5 days D. Until the lung has re-expanded

Answer: D Rationale: A chest tube (also called a chest drain or thoracic catheter) is used to treat conditions in which air or fluid enters the pleural cavity, causing lung collapse. Inserted under emergency conditions and treated as a surgical procedure, a chest tube will typically remain in place for 2-5 days until the client's x-rays indicate that all fluid or air from the pleural cavity has been removed.

The nurse preceptor is monitoring the actions of a new graduate nurse caring for a client with a tracheostomy. Which action by the new graduate requires follow-up from the preceptor? A. Suctioning the tracheostomy, then the mouth B. Assessing for irritation around the stoma C. Assessing oxygen saturation D. Suctioning secretions with a clean technique

Answer: D Rationale: Sterile suctioning, not clean, is necessary to remove these secretions from the trachea and bronchi to maintain a patent airway. It is correct to assess oxygen saturation, irritation, and suction the tracheostomy first.

The nurse taught a class about the role of the pleural membranes. Which statement by a participant indicates that learning occurred? A. "The pleural membranes contain the heart." B. "The pleural membranes warm and moisten air." C. "The pleural membranes permit gas exchange." D. "The pleural membranes help to keep the lungs inflated."

Answer: D Rationale: The pleural membranes help keep the lungs inflated; this statement indicates appropriate understanding of the content. The mediastinum contains the heart. The alveoli permit gas exchange. The bronchi warm and moisten air.

A nurse instructor is educating a group of student nurses regarding heat and cold injuries. The nurse includes which correct statement regarding thermoregulation? A) "Core temperature varies widely depending on the outside environment." B) "The body's surface temperature remains relatively constant." C) "Chemical thermogenesis occurs with the increase of cortisol." D) "All muscle activity, regardless of location, produces heat."

Answer: D Explanation: All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased thyroxine output, not cortisol.

A nurse in the operative suite is preparing an older adult for surgery. Which of the following physiological factors place the older adult at greater risk of life-threatening complications associated with surgery? Select all that apply. A. Skin elasticity B. Bladder emptying C. Tolerance for pain D. Respiratory excursion E. Cardiovascular capacity

Answer: D, E A. In older adults, atrophy and thinning of both the epithelial and subcutaneous layers of tissue occur, collagenous attachments become less effective, sebaceous gland activity decreases, and interstitial fluid decreases. These changes lead to decreased skin elasticity and the potential to take longer for an incision to heal. However, these are not life-threatening complications associated with surgery and the aging process. B. In older adults, bladder muscles weaken, bladder capacity decreases, the micturition reflex is delayed, emptying of the bladder becomes more difficulty, and residual volume increases. However, these are not life-threatening complications associated with surgery and age-related changes. C. In older adults, there is an increased threshold for sensations of pain, touch, and temperature because of age-related changes in the nerves and nerve conduction. This is not a life-threatening complication associated with surgery and the aging process. D. Age-related changes in older adults include calcification of costal cartilage (making the trachea and rib cage more rigid), an increase in the anteroposterior chest diameter, and weakening of thoracic muscles. These changes decrease respiratory excursion, which can result in multiple life-threatening postoperative complications such as atelectasis and hypostatic pneumonia. E. In older adults, there is a decrease in functioning capacity of the heart and vascular system. Atherosclerosis of the aorta, coronary arteries, and carotid arteries could decrease cardiac output, impair circulation to vital organs and distal extremities, and increase the workload of the heart at times of stress. These age-related changes are associated with life-threatening dysrhythmias, thrombophlebitis, and pulmonary emboli.

A nurse is administering a liquid medication to a 15-month-old child. What is the most appropriate approach to medication administration by the nurse? (Select all that apply.) A. Tell the child that the medication tastes just like candy. B. Mix the medication in 8 oz of orange juice. C. Ask the child if she would like to take her medication now. D. Sit the child up, hold the medicine cup to her lips, and kindly instruct her to drink. E. Offer the child a choice of cup in which to take the medicine.

Answer: D, E Rationale: Toddlers may resist taking medications. Short explanations followed by immediate (kind but firm) drug administration are best. Giving small choices such as which cup to use to take a medication allows the child some sense of control. Options 1, 2, and 3 are incorrect. For safety reasons, children should not be told that medicine is candy. A toddler is not able to make a decision regarding whether to take a medicine or not. When medication is mixed with liquids or other food products, a small amount should be used; 8 oz may be too much liquid to use for mixing. Cognitive Level: Analyzing. Nursing Process: Implementation. Client Need: Health Promotion and Maintenance.

A client is experiencing an elevated temperature. What should the nurse include in this client's plan of care? Select all that apply. A) Administer warm intravenous fluids. B) Apply warm blankets. C) Provide dry clothing. D) Increase oral fluid intake. E) Administer antipyretic medication.

Answer: D, E Explanation: The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing oral fluid intake is an intervention for an elevated body temperature. The other options would be interventions to help a client with a lower body temperature.

Which action should the nurse implement when administering an intramuscular injection into the ventrogluteal site? Select all that apply. A. Use a 1-inch needle B. Use a 25-gauge needle C. Insert the needle at a 45-degree angle D. Aspirate before instilling the medication E. Massage the insertion site after needle removal

Answer: E A. A 1.5-inch needle is required to reach muscular tissue. B. A 22-gauge needle usually is used for an intramuscular injection; a 25-gauge needle usually is used for a subcutaneous injection. C. The needle should be inserted at a 90-degree angle; a 45-degree angle is used for a subcutaneous injection when using a 1-inch needle. D. Research indicates that aspiration before instilling an intramuscular injection is not necessary when using the ventrogluteal, vastus lateralis, and rectus femoris sites. There are no major blood vessels at these sites. Aspiration is recommended before instilling the medication in the gluteus maximus site because of the close proximity of blood vessels. A blood return indicates that the needle is in a blood vessel and the procedure should be discontinued. E. Massage promotes dispersement of the medication.

TRUE or FALSE - OSHA forbid any and all recapping of needles

Answer: False Rationale: Make sure you read the statement carefully. Forbid ANY and ALL recapping. If I need to recap my needle after I have withdrawn the needle from the vial (I should never be walking around the hospital halls with a needle exposed), I am going to use a one-handed scoop method to recap a CLEAN needle. NEVER recap a dirty needle.

TRUE or FALSE - WAKE TECH Nursing Dept forbids any and all recapping of needles

TRUE or FALSE - Needle gauge is selected depending on client assessment

Answer: False Rationale: Needle gauge depends on the route first. 25 gauge for subcutaneous. For IM injections the needle gauge depends on the viscosity of the drug. A viscous med (like Ativan or some antibiotics) would be given with a large gauge needle (18-21), whereas non-viscous drugs are 22-25 gauge.

True/false: it is important to assess the client's response to a medication, especially if it is the first dose.

Answer: True

A nurse is caring for a client who is newly admitted to the facility for chest pain. At which of the following times should the nurse begin teaching about drugs and discharge planning? [] after the client has a definitive diagnosis [] on the day of discharge [] when the client's family members are present [] as soon as possible

As soon as possible

A nurse is caring for a client in the intensive care unit who is intubated and mechanically ventilated. Upon assessment, the nurse notes the client has cheilosis. Based on this data, which is the priority intervention for this client? A. Providing oral care B. Lubricating the lips using an antimicrobial ointment C. Checking for ill-fitting dentures D. Suggesting an increase in fluid intake

After conducting a physical assessment for an adult client, the nurse discusses the assessment with a coworker and states that the client's beliefs and actions regarding common health practices are unfamiliar to her. Based on this data, which action by the nurse is the most appropriate? A. Communicate the findings to the healthcare team. B. Determine the culture with which the client identifies. C. Repeat the assessment later in the day. D. Write a nursing diagnosis to address the unfamiliar beliefs and actions.

For a client with chronic obstructive pulmonary disease (COPD), the nurse may provide health promotion teaching about what other major health concept? A. Immunity B. Safety C. Development D. Elimination

The nurse is caring for a client who is admitted to the hospital with a diagnosis of pneumonia. The client is on a monitor, and vital signs are recorded from the monitor in order to leave the client undisturbed during the night. The nurse observes that blood pressure, heart rate, and respirations are below baseline for this client. Based on this data, which conclusion by the nurse regarding the changes in vital signs is the most appropriate? A. The client's metabolic rate has increased. B. The client is in NREM sleep. C. The client is about to have a cardiac arrest. D. The client is in REM sleep.

The portion of the tooth that wears away, allowing dental decay, is the A. gingiva. B. enamel. C. pulp cavity. D. root.

When talking to a client about sleep patterns, one of the most important interventions the nurse can suggest for clients who are having difficulty sleeping is to A. do a calming activity in bed before trying to sleep, such as reading a book. B. set a routine time to go to bed and a routine time to get out of bed. C. eat a small snack before bedtime. D. take an over-the-counter sleep aid such as melatonin.

9) A client recovering from surgery begins to have an increase in body temperature and carbon dioxide level. What should the nurse do first? A) Assess for patent intravenous line. B) Provide 100% oxygen with a nonrebreather mask. C) Provide dantrolene. D) Contact the anesthesiologist.

B An increase in body temperature and carbon dioxide level are indications that the client is developing malignant hyperthermia. The first thing the nurse should do is apply 100% oxygen with a nonrebreather mask. The nurse should then ensure good intravenous access and contact the anesthesiologist. The anesthesiologist will prescribe dantrolene for administration.

The nurse is caring for an older adult patient who requires an assistive device for ambulation. Which device should the nurse recommend for the patient? A. Wheelchair B. Walker C. Crutches D. Cane

B An older adult patient may feel unstable on crutches or not have the strength, so the best assistive device for ambulation is a walker with its large base. Middle-aged adults might prefer a cane or crutches. The wheelchair is not an ambulation device.

6) A client has been receiving treatment for hypothermia. What would indicate that interventions have been successful? A) Current temperature of 95°F B) Heart rate of 72 and regular C) Continues to shiver D) Blood pressure of 88/54 mmHg

B Evidence of successful treatment for hypothermia is a heart rate of 72 and regular. The other findings indicate a continued low body temperature.

A nurse is caring for a patient who has a tracheostomy. Which of the following must the nurse use when administering oxygen to this patient? A) Distilled water for humidification B) A tracheostomy collar C) An inner tracheostomy cannula D) An aerosol mask

B) A tracheostomy collar

A nurse is caring for a patient who is dyspneic and slightly cyanotic, with a respiratory rate of 28/min. The nurse determines that the patient has impaired gas exchange during which of the following phases of the nursing process? A) Assessment B) Diagnosis C) Planning D) Evaluation

B) Diagnosis

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client? A) Risk for Infection B) Impaired Spontaneous Ventilation C) Risk for Acute Confusion D) Decreased Cardiac Output

B) Impaired Spontaneous Ventilation

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a decrease of cardiac output secondary to positive pressure ventilation? A) Blood pressure increases from 88/58 mmHg to 90/60 mmHg B) Urine output decreases from 30 mL/hr to 25 mL/hr C) Heart rate drops from 108 bpm to 104 bpm D) Oxygen saturation increases from 82% to 90%

B) Urine output decreases from 30 mL/hr to 25 mL/hr

The client with ARDS who is likely to have the poorest outcome is A) a Hispanic male with pneumonia. B) an African American male with sepsis. C) a Caucasian female with sepsis. D) an African American female with chest trauma.

B) an African American male with sepsis.

A home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must A) clean the mask with soapy water every other day. B) reposition the elastic band frequently. C) apply petroleum jelly around and inside the nares. D) make sure there is adequate condensation in the tubing.

B) reposition the elastic band frequently.

The nurse admits a client suspected of having nerve problems. Which diagnostic test should the nurse expect the client's healthcare provider to order? (Select all that apply.) A. Dual-energy x-ray absorptiometry B. Electromyography C. Nerve conduction studies D. Peripheral bone density E. Dual-photon absorptiometry

B, C Rationale: Electrical studies are used to determine electrical activity of the muscles or identify nerve compression and include electromyography and nerve conduction studies. Diagnostic tests that produce an image include peripheral bone density, dual-photon absorptiometry, and dual-energy x-ray absorptiometry.

The family of an older adult client tells the nurse that they want their mother to remain as active as possible for as long as possible. Which instruction should the nurse provide the family? (Select all that apply.) A. Daily stretching B. Regular exercise C. Adequate rest and sleep D. Adequate calcium intake E. Good nutritional intake

B, D, E Rationale: The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good nutrition, adequate calcium intake, and regular exercise. Daily stretching and adequate rest and sleep are not specific strategies to prevent the development of musculoskeletal status disorders.

A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? A. "I will straighten my ear canal by pulling my ear down and back." B. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal."

B. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." Rationale: A. The client should straighten his ear canal by pulling the auricle upward and outward to open up the ear canal and allow the medication to reach the eardrum. B. Correct: The client should gently apply pressure with the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal. C. The client should never occlude the ear canal with the dropper when instilling ear drops because this can cause pressure that could injure the eardrum. D. The client should not place a cotton ball past the outermost part of the ear canal because it could introduce bacteria to the inner or middle ear.

A client has been diagnosed with borderline hypertension and is given a blood pressure monitor to take daily BP readings. What instructions would be appropriate for the nurse to give the client for taking home blood pressure? A. "Blood pressure readings will be erroneously high if the arm is above the level of the heart." B. "Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated beverages." C. "Take blood pressure at different times every day to be sure it is not elevated at different times of the day." D. "Blood pressure should be taken before getting up in the morning, with the arm elevated over the level of the heart."

B. "Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated beverages." Rationale: The American Heart Association recommends clients who monitor blood pressure at home do so with an automatic BP cuff. Measurements should be taken with the client seated, having rested for at least 5 minutes prior, and at least 30 minutes after drinking caffeinated beverages. Blood pressure should be taken at about the same time each day, and the client should keep a log of blood pressure readings. Blood pressure readings will be erroneously low if the blood pressure is taken with the arm above the level of the heart.

A client who has been diagnosed with new onset atrial fibrillation has been prescribed warfarin, an anticoagulant. Which statement of instruction should the nurse provide? A. "Do not take warfarin if your pulse is below 65." B. "You should shave with an electric razor." C. "It is recommended that you avoid eating foods high in protein." D. "Take an additional warfarin if you heart rate increases."

B. "You should shave with an electric razor." Rationale: Warfarin is an anticoagulant used to prevent the formation of clots in clients with atrial fibrillation. Clients who take warfarin should be on bleeding precautions, because the ability of their blood to form clots is compromised. Clients should be instructed to shave with an electric razor and avoid working with sharp objects. Clients should notify the technician prior to having blood drawn.

A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? A. Taking all medications out of the unit-dose wrappers before entering the client's room B. Checking with the provider when a single dose requires administration of multiple tablets C. Administering a medication, then looking up the usual dosage range D. Relying on another nurse to clarify a medication prescription

B. Checking with the provider when a single dose requires administration of multiple tablets Rationale: A. To prevent errors, the nurse should not take unit-dose medications out of wrappers until at the bedside when preforming the third check of medication administration. The nurse can encourage clients' involvement and provide teaching at this time. B. Correct: If a single dose requires multiple tablets, it is possible that an error has occurred in the prescription or transcription of the medication. This action could prevent a medication error. C. Reviewing the usual dosage range prior to administration can help the nurse identify an inaccurate dosage. D. If the prescription is unclear, the nurse should contact the provider, not another nurse, for clarification.

The nurse is caring for a client with congestive heart failure (CHF). Which medication should the nurse expect the healthcare provider to prescribe to rid the client's body of excess fluids and reduce edema? A. Beta blocker B. Diuretic C. Calcium channel blocker D. Anticoagulant

B. Diuretic Rationale: Diuretics pull fluids from the extravascular spaces into the blood vessels, where excess fluid is then filtered and eliminated through the urinary system. Diuretics are often given to clients with CHF to prevent the collection of fluid in the lungs. A client with CHF can develop difficulty breathing if fluid builds up around the lungs as a result of edema. Diuretics should be used with caution to prevent too much fluid loss. Anticoagulants are used to prevent clot extension and lower the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Calcium channel blockers (CCBs) decrease automaticity and AV nodal conduction. Beta blockers decrease heart rate and myocardial contractility.

A client who is obese and who has a history of heart disease and heart failure (HF) is in an intensive care unit. The client is having a very difficult time getting comfortable in bed. The client has difficulty sleeping and becomes short of breath upon lying down in bed. Which nursing intervention could help promote comfort? A. Increasing the client's oxygen at night B. Elevating the head of the bed and providing extra pillows C. Obtaining an order for a sleeping pill D. Advising family to stay with the client at night

B. Elevating the head of the bed and providing extra pillows. Rationale: Elevating the head of the bed can help those with heart failure or poor perfusion breathe more comfortably. Increasing oxygen may provide some short-term relief, but it will not help with client comfort in the long term. The nurse should assist the client into a position of comfort, with extra pillows and the head of the bed elevated, and promote a restful environment in the room. Clients with poor perfusion are often unable to lie flat due to decreased pulmonary perfusion, which provides oxygen to the bloodstream. In clients with HF, the nurse should anticipate assisting with positions of comfort.

A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine toxicity C. Decreased risk of adverse effects of cimetidine D. Increased therapeutic effects of imipramine

B. Increased risk of imipramine toxicity Rationale: A. A medication that increases the metabolism of another medication can decrease the effectiveness of that medication. B. Correct: A medication that decreases the metabolism of another medication increases the serum level of that medication, increasing the risk for toxicity. C. A medication that decreases the metabolism of another medication does not decrease the risk for adverse effects. D. A medication that decreases the metabolism of another medication does not increase the medication's therapeutic effects.

A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? A. Increasing the metabolism of the medications over time B. Increasing the protein-binding response C. Increasing medications' transit time through the intestines D. Decreasing the excretion of medications

B. Increasing the protein-binding response Rationale: A. Some medications, not fasting, cause metabolic tolerance as metabolism of the medication increases over time and the effectiveness of the medication declines. B. Correct: Inadequate nutrition, such as starvation, can affect the protein-binding response of medications. It increases their response and thus increases the risk for medication toxicity. C. Disorders that cause diarrhea, not fasting, cause oral medications to pass through the gastrointestinal tract too quickly for adequate absorption. This mechanism does not cause toxicity. D. Kidney disease or failure, not fasting, prevents or delays medication excretion, which can cause toxicity.

A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply.) A. Increased gastric acid production B. Lower blood pressure C. Higher body water content D. Increased absorption of topical medications E. Increased gastric emptying time

B. Lower blood pressure; C. Higher body water content; D. Increased absorption of topical medications Rationale: A. Children have decreased gastric acid production. B. Correct: Children have a lower blood pressure. C. Correct: Children have a higher body water content. D. Correct: Children have increased absorption of topical medications. E. Children have a slower gastric emptying time.

To promote adherence with medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply.) A. Adjust dosages according to daily weight. B. Place pills in daily pill holders. C. Ask for liquid forms if the client has difficulty swallowing pills. D. Ask a relative to assist periodically. E. Request child-resistant caps on medication containers.

B. Place pills in daily pill holders; C. Ask for liquid forms if the client has difficulty swallowing pills; D. Ask a relative to assist periodically Rationale: A. The provider adjusts the client's dosages. Instructing the client to base dosages on daily weight increases the risk for error in medication self-administration. B. Correct: Organizing medications in daily pill holders promotes medication adherence. C. Correct: Providing a form of medication that is easier for the client to swallow promotes medication adherence. D. Correct: Including the client's support system promotes medication adherence. E. Some older adult clients have difficulty opening child-resistant caps. Request easy-open containers from the pharmacy.

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22-gauge needle. B. Select a site on the client's abdomen. C. Spread the skin with the thumb and finger. D. Observe for bleb formation to confirm proper placement.

B. Select a site on the client's abdomen. Rationale: A. For a subcutaneous injection, the nurse should use a 25- to 27-gauge needle. B. Correct: For a subcutaneous injection, the nurse should select a site that has an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs). C. For a subcutaneous injection, the nurse should pinch the skin with her thumb and index finger. D. Bleb formation confirms injection into the dermis, not into subcutaneous tissue.

A critical nursing concept that a nurse uses with every client that allows the nurse to identify habits of health and wellness and the effects of illness and injury is A. collaboration. B. advocacy. C. assessment. D. teaching and learning.

A nurse is teaching a couples' class at a local community center about building positive relationships. Today's session is on learning skills to be open-minded and respectful to those with opposing opinions. Based on this data, on which component of wellness is the nurse focusing this session? A. Emotional B. Physical C. Social D. Environment

A nursing diagnosis that indicates that a client wants to implement steps to promote health and wellness usually includes the word(s) A. ineffective. B. impaired. C. readiness for. D. risk for.

A pediatric nurse is assigned telephone triage for the day at a pediatric clinic. The nurse receives a phone call from the mother of a newborn. The mother states, "I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesn't breathe regularly, and she sometimes twitches." Based on this data, which response by the nurse is the most appropriate? A. "If your baby does this again, take her to the emergency department." B. "You should ask the doctor about these symptoms at your next checkup." C. "These are common behaviors in newborns and are normal." D. "Please bring your baby in immediately for a checkup."

Physical activity and exercise improve the functioning of many body systems. Exercise improves what normal body function of the gastrointestinal system? A. Use of fatty acids B. Insulin responsiveness C. Peristalsis D. Metabolic rate

The nurse is providing care to an older adult client who was recently diagnosed with early osteoporosis. Which intervention is most appropriate for the nurse to implement with this client? A. Increasing the amount of calcium in the client's diet B. Protecting the client's bones with strict bedrest C. Instituting an exercise plan that includes weight-bearing activities D. Providing the client with assisted range of motion exercising twice daily

During assessment of a patient with an alteration in mobility, the nurse notices that the patient has become confused and is having hallucinations. Which medication should the nurse suspect is causing the patient's symptoms? A. Nonsteriodal anti-inflammatory drugs (NSAIDs) B. Bisphosphonates C. Skeletal muscle relaxants D. Hormones

C Antispasmodics (skeletal muscle relaxants) act in the central nervous system (CNS) to decrease nerve transmission to skeletal muscles. Patients should be carefully observed for CNS effects including confusion, depression, and hallucinations. Nonsteroidal anti-inflammatory drugs may cause gastrointestinal upset or bleeding. Patients taking bisphosphonates should be monitored for renal or liver impairment. Hormones do not cause CNS effects.

The nurse is reviewing the medication record of a patient admitted with an alteration in mobility. Which class of medications should lead the nurse to carefully observe the patient for central nervous system (CNS) effects? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B. Bisphosphonates C. Skeletal muscle relaxants D. Hormones

1) Victims of a boating accident were admitted to the hospital with the diagnosis of hypothermia. What should the nurse realize as the method by which these clients lost body temperature? A) Vaporization B) Insensible water loss C) Convection D) Insensible heat loss

C Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Vaporization is the continuous evaporation of moisture through the respiratory tract, mucosa of the mouth, and skin. Insensible water loss is unnoticed water loss through vaporization. Insensible heat loss is the loss of heat through vaporization.

The nurse teaches a patient with altered mobility about the importance of exercise. Which patient statement indicates that further teaching is necessary? A. "Exercise helps reduce the stiffness in my joints." B. "I should exercise to increase my endurance." C. "I should not exercise when I am on bedrest." D. "Exercise will prevent my muscles from becoming weak."

C Exercise is vital to maintaining muscle strength, especially during prolonged bedrest. The patient on bedrest should perform exercises to prevent atrophy and weakness of the muscles. Exercise also promotes strength and range of motion (ROM), reduces joint pain and stiffness, and increases flexibility and endurance.

The nurse assesses a patient diagnosed with an alteration in mobility. Which assessment finding should the nurse determine as not related to immobility? A. Atelectasis B. Pneumonia C. Increased gastrointestinal motility D. Pressure injury on the coccyx

C Immobility can exacerbate any existing musculoskeletal impairment. It can also lead to atelectasis and pneumonia, decreased gastrointestinal motility, and paralytic ileus. Impaired tissue perfusion due to immobility may cause pressure injury.

The nurse taught a client about ways to prevent alterations in mobility. Which client behavior indicates that the teaching has been effective? (Select all that apply.) A. Client applies ice to inflamed joints twice a day B. Client smokes a half pack of cigarettes per day C. Client drinks milk with every meal D. Client walks every day for 30 minutes E. Client consumes fresh fruits and vegetables every day

C, D, E Rationale: The best way to avoid an alteration in mobility is to prevent the development of musculoskeletal disorders. Prevention strategies include good nutrition, adequate calcium intake, and regular exercise. Drinking milk, walking, and consuming fresh produce indicate actions to prevent the development of musculoskeletal disorders. Smoking is not a healthy activity. Applying ice to inflamed joints indicates an alteration in mobility already exists.

A client is prescribed cardiac rehabilitation and asks why it is necessary. Which response by the nurse expresses the goals of this program? A. "Your blood pressure is elevated and this program will help to decrease your blood pressure and reduce your risk of having a heart attack." B. "You have been diagnosed with congestive heart failure (CHF) and this program will help improve the amount of blood and oxygen distributed to your muscles." C. "Because you have had a cardiac injury, this program will provide the opportunity for your heart to reach optimal function." D. "As you go through cardiac rehabilitation, you will gradually regenerate cardiac muscle tissue that will improve your heart function."

C. "Because you have had a cardiac injury, this program will provide the opportunity for your heart to reach optimal function." Rationale: Cardiac rehabilitation is a medically supervised program of exercise and lifestyle modification that aids people who have had a cardiac injury due to myocardial infarction (MI), heart failure, heart surgery, or interventional cardiology to maintain optimal cardiac function in the remaining heart tissue. Cardiac rehabilitation is recommended for anyone who has had a heart attack, and it can help individuals resume a high quality of life after cardiac injury.

A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority? A. Teaching the client about the purpose of the medication B. Giving the medication at the administration time the provider prescribed C. Identifying the client's medication allergies D. Documenting the client's anxiety level

C. Identifying the client's medication allergies Rationale: A. The nurse should teach the client about the purpose of the medication to make sure the client understands why the provider prescribed it. However, another action is the priority. B. The nurse should administer the medication at the time the provider prescribed that the client receive it to help prepare the client for the surgical procedure. However, another action is the priority. C. Correct: The greatest risk to this client is injury form an allergic reaction. The priority action is to identify the client's allergies prior to medication administration. D. The nurse should document the client's anxiety level to have a baseline against which to measure the effectiveness of the medication. However, another action is the priority.

A nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. The client states his pain level is 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO

C. Morphine 2 mg IV Rationale: A. Although meperidine is a strong analgesic, the IM route of administration can allow for slow absorption, delaying the onset of pain relief. The IM route also can cause additional pain from the injection. B. Although fentanyl is a strong analgesic, the transdermal route of administration can allow for slow absorption, delaying the onset of pain relief. C. Correct: The nurse should administer IV morphine because the onset is rapid, and absorption of the medication into the blood is immediate, which provides the optimal response for a client who is reporting pain at a level of 10. D. Although oxycodone is a strong analgesic, the oral route of administration of this medication can allow for onset of pain relief in 10 to 15 min, which can be a long time for a client who is reporting pain at a level of 10.

A nurse obtains a client's radial pulse and notes that it is rapid and very irregular. What is the most appropriate action for the nurse to take? A. Ask another nurse to attempt a radial pulse measurement. B. Document the best estimation of the pulse. C. Obtain an apical pulse for 1 minute. D. Have the client lie still for 5 minutes and attempt another measurement.

C. Obtain an apical pulse for 1 minute. Rationale: An apical pulse is auscultated directly over the apex of the heart. This is truly the most accurate measurement of how many times a heart circulates blood each minute. The most frequently used site for obtaining a pulse is the radial pulse, due to the convenience of this site, but any client who has an irregular or difficult-to-obtain radial pulse should have an apical pulse taken for a full minute and documented.

Which is most likely to be a normal assessment finding in an 80-year-old client? A. Blood pressure of 160/90 mmHg B. Heart rate of 110 beats/min C. Resting heart rate of 62 beats/min D. Irregular heart rhythm

C. Resting heart rate of 62 beats/min Rationale: Resting heart rate is relatively unchanged with normal aging. Blood pressure of 160/90 mm/Hg is elevated and not normal for an adult. While BP elevation frequently occurs with aging, it is not considered a normal variant. A heart rate over 110 beats/min is not considered normal for an older adult. An irregular heart rhythm is an expected finding that may be controlled, but it is not a normal assessment finding.

A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? A. Drink 8 oz milk with each dose of medication. B. Use medications that have an extended half-life. C. Take each dose right after breastfeeding. D. Pump breast milk and freeze it prior to feeding to the newborn.

C. Take each dose right after breastfeeding Rationale: A. The intake of food or fluid with medication does not affect entry of medications into breast milk. B. The client should avoid medications that have an extended half-life due to their increased entry into breast milk. C. Correct: Taking medication immediately after breastfeeding helps minimize medication concentration in the next feeding. D. Pumping and freezing breast milk does not affect entry of medications into breast milk.

A nurse is caring for a client who is taking acetaminophen and codeine for pain relief. These analgesic drugs interact with one another to cause an additive effect. The nurse should identify that which of the following are characteristics of additive drug interactions? (select all that apply) [] clients can achieve desired effects with the use of lower dosages [] taking the two drugs together can reduce the effects of one or both drugs [] taking the two drugs together can potentiate the effects of one or both drugs [] the two drugs can produce an action neither would have produced alone [] both drugs have similar actions

Clients can achieve desired effects with the use of lower dosages is correct. *When two or more drugs are given at the same time and have similar actions, an additive effect will occur. Clients can take some drugs together for their additive effects, so they can take lower doses of each drug. Both drugs have similar actions is correct. *Additive effects occur when two or more drugs with similar actions are taken at the same time.

A nurse is preparing to administer a drug to a client. In which of the following sections of a drug handbook should the nurse look to determine if the client can receive the drug? [] adverse effects [] contraindications [] implementation [] black box warning

Contraindications The nurse should review the contraindications section in the drug handbook to determine if a client can receive the drug. This section lists pre-existing diseases or clinical situations that could make it unsafe to administer a drug.

A nurse is caring for a client with glossitis secondary to nutritional deficiencies. Based on this data, which is the priority focus of this client's care? A. Upper teeth B. Uvula C. Upper lip D. Tongue

The nurse working in the newborn nursery understands that a neonate has differences in sleeping patterns and stages than an older child or an adult. Which statement related to sleep is incorrect for a newborn? A. A newborn will have an irregular sleep schedule with periods of 1-3 hours spent awake. B. NREM sleep is also called quiet sleep during the newborn period. C. NREM sleep in a newborn is characterized by regular respirations, closed eyes, and the absence of body and eye movements. D. REM sleep occurs gradually in a newborn.

2) During an assessment, a client who was a victim of an industrial accident has a mildly elevated body temperature. To what should the nurse attribute the client's increase in body temperature? A) Infection B) Diet C) Exercise D) Stress

D Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to suspect infection. The client was not exercising. Diet does not influence body temperature.

A nurse is preparing to administer digoxin to a client who states, "I don't want to take that medication. I do not want one more pill." Which of the following responses should the nurse make? A. "Your physician prescribed it for you, so you really should take it." B. "Well, let's just get it over quickly then." C. "Okay, I'll give you your other medications." D. "Tell me your concerns about taking this medication."

D. "Tell me your concerns about taking this medication." Rationale: A. This response dismisses the client's concerns. B. The nurse is dismissing the client's concerns about taking the medication by continuing with medication administration. C. Although clients have the right to refuse a medication, the nurse should provide information about the risk of refusal instead of proceeding with medication administration. D. Correct: Although clients have the right to refuse a medication, the nurse is correct in determining the refusal by asking the client his concerns. Then the nurse can provide information about the risk of refusal and facilitate an informed decision. At that point, if the client still exercises his right to refuse a medication, the nurse should notify and the provider and document the refusal and the actions the nurse took.

A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make? A. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." B. "You can safely take over-the-counter medications." C. "You should avoid any vitamin preparations containing iron." D. "Your provider can prescribe medication for nausea if you need it."

D. "Your provider can prescribe medication for nausea if you need it." Rationale: A. Pregnancy is a contraindication for live-virus vaccines, including rubella, due to possible teratogenic effects. B. Most medications, including over-the-counter, are potentially harmful to the fetus. The client should avoid any medications unless her provider prescribes them. C. Nutritional supplements that include iron are common recommendations during pregnancy to support the health of the mother and fetus. D. Correct: Providers can prescribe medications to treat nausea and other discomforts of pregnancy.

A client with impaired perfusion has finished ambulating with physical therapy. He is short of breath and fatigued. His heart rate was 60 beats/min before physical therapy and 68 beats/min after physical therapy. Which drug is likely the reason for the low heart rate? A. Analgesic agent B. Angiotensin-converting enzyme (ACE) inhibitor C. Antihypertensive agent D. Beta blocker

D. Beta blocker Rationale: Beta blockers (also called beta-adrenergic blocking agents) "block" the effects of epinephrine and norepinephrine on the body's beta-adrenergic receptors, resulting in decreasing myocardial contractility and reducing the heart rate. The nurse should be aware of the decreased heart rate in clients who take beta blockers and allow adequate rest to ensure optimum cardiac output during exercise. Antihypertensive agents lower blood pressure. Analgesics are used to alleviate pain. ACE inhibitors interfere with the production of angiotensin II, resulting in vasodilation and reduced blood volume.

A 65-year-old client presents to the emergency department with a 3-day history of diarrhea and vomiting. The nurse notices that the client's pulse is 128 bpm. What is the most likely cause of the increased heart rate? A. Stress from being sick B. Effects of medications the client has taken C. The client's age D. Dehydration from loss of fluids

D. Dehydration from loss of fluids Rationale: Pulse rate will increase in response to hypovolemia to maintain an adequate cardiac output. Factors such as stress, age, medications, exercise, and lifestyle can alter a person's pulse. In this scenario, the client had a history of diarrhea and vomiting and likely was experiencing hypovolemia. The nurse should expect to begin IV fluid hydration.

Which ECG change indicates decreased perfusion to the myocardial muscle and possible impending ischemia? A. Elevated ST segment B. Absence of P waves C. Widened QRS complex D. Depressed ST segment

D. Depressed ST segment Rationale: A depressed ST segment indicates a decrease in perfusion to the myocardial tissue. This could indicate a developing ischemia or infarction. An elevated ST segment indicates an active infarction. Absence of P waves is an indication of atrial fibrillation, which may decrease overall perfusion, but can be managed. A widened QRS complex can occur when cardiac conduction pathways are interrupted or delayed.

A 62-year-old female client has been diagnosed with narrowing of the coronary arteries. What would be the appropriate, conservative initial treatment for this condition? A. Eat a diet with a minimum of 20% fat. B. Take statin medications as prescribed. C. Cut smoking by half the usual amount. D. Exercise for 30 minutes 3 times a week.

D. Exercise for 30 minutes 3 times a week. Rationale: Conservative treatment would include regular physical exercise such as walking at a brisk pace. Fat should be no more than 10% of the daily diet. Smoking should be totally eliminated, usually through a cessation program or the use of assistive drugs such as nicotine patches. By controlling cholesterol, the client can help control coronary artery disease (CAD). The statins are one group of medications used to decrease circulating cholesterol. Prescribing a statin would be a more aggressive treatment.

A community health nurse is educating a group of clients on the difference between illness and disease. Which statements are appropriate for the nurse to include in the educational session? Select all that apply. A. "Illness is synonymous with disease." B. "Illness and disease are never related to one another." C. "Illness is an alteration in body function, where disease is highly subjective." D. "An individual can feel ill without disease." E. "An individual can have a disease and not feel ill."

A nurse is caring for a client who has a history of renal insufficiency and is taking lithium. The nurse should monitor the client for which of the following? [] tolerance to the drug [] drug interaction [] drug toxicity [] dependence on the drug

Drug toxicity Drug toxicity develops when the amount of a drug that is taken is greater than its rate of excretion, and it results in the drug accumulating in the body. A client who has renal insufficiency might have delayed or impaired excretion of the drug. The drug dosage should be reduced if toxicity occurs.

A nurse is speaking to a client who is taking sertraline and reports drinking grapefruit juice. The nurse explains that grapefruit juice inhibits an enzyme in the liver that is used to metabolize sertraline. The nurse should recognize the client's risk for which of the following? [] reduced drug absorption [] drug dependence [] altered drug distribution [] drug toxicity

Drug toxicity Grapefruit juice can cause increased levels of certain drugs, such as sertraline, which can lead to drug toxicity. Clients should avoid drinking grapefruit juice while taking these drugs.

A nurse is caring for a client who is having difficulty remembering to take their prescribed drug three times each day. The nurse should identify that which of the following alternate forms of the drug can help to promote adherence to the prescribed dosage? [] liquid suspension [] immediate-release capsule [] extended-release tablet [] powder form

Extended-release tablet Extended-release tablets release the drug over an extended period of time. Clients can take them less frequently.

A nurse is administering a subcutaneous injection to a patient. Which of the following data should the nurse recognize as the highest priority to prevent potential complications? -Identify the patients knowledge about the medication -Identify if the patient has allergies to the medication -Identify a specific site for the injection -Identify the rationale for the patient receiving the medication

Identify if the patient has allergies to the medication

Which of the following is your highest priority action for ensuring overall safety during medication administration? -Have mother nurse check the dose you will give -Teach the patient about possible adverse effects -Identify the patient by two acceptable methods -Confirm that the patient can swallow adequately

Identify the patient by two acceptable methods

A nurse is preparing to administer a drug to a client. In which of the following sections of a drug handbook should the nurse look to determine if the drug has more than one use? [] Adverse effects [] indications [] pharmacokinetics [] nursing implications

Indications is Correct The indications section provides information on conditions and diseases for which the drug is used. Adverse effects This section categorizes the adverse effects of a drug. Pharmacokinetics The pharmacokinetics section outlines how the drug is processed in the body through absorption, distribution, metabolism, and excretion, but it does not address the disease or conditions that the drug is used to treat. Nursing implications The nursing implications section explains how the nurse will apply the nursing process to the use of the drug.

A nurse is reviewing a drug handbook prior to administering a drug to a client who has kidney disease. The handbook states that the drug can be administered but identifies certain risks. Which of the following terms describes these risks? [] contraindications [] precautions [] paradoxical effects [] adverse effects

Precautions A precaution includes disease states, such as kidney disease, or clinical situations in which use of a drug involves particular risks or dosage modification might be necessary.

A nurse is preparing to instill antibiotic ear drops into a toddler's ear. Which of the following techniques should the nurse use when administering ear drops to this patient? Have the patient maintain side-lying position for 30 min after administration of ear drops. Pull the patient's auricle down and back to open the canal when administering ear drops. The nurse should don sterile gloves prior to administration of ear drops. Insert the tip of the dropper into the ear canal when administering ear drops.

Pull the patient's auricle down and back to open the canal when administering ear drops.

A client appears anxious and nervous upon entering the healthcare provider's office. The nurse takes a blood pressure reading and notes that it is elevated. What is the next appropriate action the nurse should take? A. Instruct the client to calm down so accurate vital signs can be obtained. B. Have the client rest quietly for 5 minutes and retake the blood pressure. C. Document the blood pressure and tell the physician the client is anxious. D. Ask the client to tell you her usual blood pressure

Rationale: Clients may be anxious when seeking medical care in a physician's office. If a client appears anxious and the nurse obtains an elevated blood pressure reading, the nurse should promote a calm, reassuring environment and obtain the blood pressure again. A client presenting with anxiety should be assessed for underlying causes. It is important to reassure clients but also obtain accurate blood pressure readings.

You are giving a patient several PO medications to take. The patient tells you that she can only take one pill at a time. It is appropriate to -Place all of the medications in a cup & let the patient decide the order in which to take them -Crush the pills & mix them i applesauce -Remain at the bedside until you are sure the patient has taken all of the medications -Leave the pills at the bedside for the patient to take

Remain at the bedside until you are sure the patient has taken all of the medications

A drug's generic name is the -Chemical name or the medication -Same as the nonproprietary name -Name under which the drugs is marketed -Formal name of the particular drug

Same as the nonproprietary name

Compare the oral, topical, IM, subcutaneous, and IV routes. Which has the fastest onset of drug action? Which routes avoid the hepatic first-pass effect? Which require strict aseptic technique?

The IV route has the fastest onset because medications are administered directly into the bloodstream. IV medications also bypass the first-pass effect. When administering parenteral medications (IV, intradermal, subcutaneous, and IM routes), the nurse must ensure that aseptic techniques are strictly used.

A nurse is caring for a client who is taking diphenhydramine for insomnia and reports drowsiness. The nurse should identify that drowsiness indicates which of the following? [] therapeutic effect [] adverse reaction [] contraindication [] precaution

Therapeutic effect Drowsiness is a therapeutic effect of diphenhydramine for a client who is taking the drug to treat insomnia.

A nurse is obtaining a client's health history and discovers that the client takes loratadine, an over-the-counter drug. The nurse should identify that which of the following is correct regarding the over-the-counter drugs? (select all that apply) [] they do not require the supervision of a nurse [] they can interact with other drugs [] they should be included in the client's drug history assessment [] they are less effective than prescription drugs [] they do not cause toxicity

They do not require the supervision of a nurse is correct. *Over-the-counter drugs do not require a prescription or the supervision of a nurse. They can interact with other drugs is correct. *Many over-the-counter drugs interact with other drugs. They should be included in the client's drug history assessment is correct. *Over-the-counter drugs are often omitted from the drug history assessment, but they should be included. Nurses should ask specific questions about over-the-counter drugs and herbal remedies.

What strategies can the nurse employ to ensure drug compliance for a client who is refusing to take his or her medication?

To help ensure adherence to drug therapy, the nurse should formulate an individualized plan of care with the client using the nursing process. Including the client in this process enables the client to participate fully, which encourages better adherence to the treatment plan. The nurse should also explore reasons the client may be refusing a medication, such as cost or unpleasant effects, in order to work with the provider on possible alternatives.

A nurse is preparing to administer an intradermal injection. Which of the following should the nurse do to ensure proper technique? -Rub the injection site after withdrawing the needle -Pinch 1/2 in of the skin & administer the injection at 45 degree angle -Use a tuberculin Syringe w/ a 3/8-5/8 in, 25-27 gauge needle -Choose a site at least 2 in from the umbilicus

Use a tuberculin Syringe w/ a 3/8-5/8 in, 25-27 gauge needle

While teaching a class on health status, the nurse educator reviews internal variables that affect health status. Which internal variables are appropriate for the nurse to include in the class? Select all that apply. A. Gender B. Age C. Developmental level D. Exercise regimen E. Diet

aabc

The nurse is caring for a client who can bear weight but has a weak limb. Which assistive device is the most appropriate for this client? A. Cane B. Walker C. Wheelchair D. Crutches

A Rationale: Assistive devices are used to provide balance and support and increase confidence with independent ambulation. They also reduce pressure on an injured limb, prevent further injury, and promote healing. Canes are used by clients who can bear weight but are unsteady or have a weak limb. When using a walker, the arms support the majority of the body weight. For crutches, upper body and trunk strength is needed. A wheelchair will not assist with ambulation. Next Question

Which type of exercise should the nurse implement to maintain the strength of a limb with an immobilized joint? A. Range-of-motion exercise B. Isometric exercise C. Passive exercise D. Resistive exercise

B Rationale: Isometric exercise is used to maintain strength when a joint is immobilized. It is performed by contracting a specific muscle group against another muscle group or immovable object. Resistive exercise is active exercise where the client works against resistance to increase muscle strength. Range-of-motion exercises help maintain joint mobility during periods of restricted activity. Passive exercises are performed by a physical therapist or nurse for the client.

A nurse is teaching a client about naproxen enteric-coated tablets. Which of the following statements should the nurse include in the teaching? [] "drug absorption occurs in the stomach." [] "you should expect immediate absorption of the drug." [] "you should allow the tablet to dissolve in your mouth." [] "do not crush or chew the tablet."

"do not crush or chew the tablet." Drugs that irritate the stomach are often covered with an enteric coating that does not dissolve until the drug enters the alkaline environment of the small intestine. Clients should not crush or chew enteric-coated drugs because this will damage the enteric coating.

A nurse is obtaining a client's health history. The client reports no allergies but has experienced mild itching while taking amoxicillin in the past. Which of the following responses should the nurse make? [] "itching is an expected adverse effect of amoxicillin." [] "itching can indicate amoxicillin toxicity." [] "itching can indicate a hypersensitivity to amoxicillin." [] "itching can result from dry skin, which is often caused by amoxicillin."

"itching can indicate hypersensitivity to amoxicillin. Itching can be an indication of drug hypersensitivity, and a more severe allergic reaction can develop with future exposures. The client might be allergic to amoxicillin and other penicillins.

Which of the following demonstrates the correct use of one of the six rights of medication administration/ -Administering a patient's medication by the route the provider has prescribed -Adhering as closely as possible to the medication schedule the patient follows at home -Gathering a medication history from the patient before administering any drugs -Respecting a patient's refusal to take a new medication the provider has prescribed

-Administering a patient's medication by the route the provider has prescribed

3) The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status? A) Encourage fluids. B) Limit fluids. C) Monitor output. D) Maintain intravenous therapy until day before discharge.

Answer: A

5) The nurse is caring for an infant diagnosed with patent ductus arteriosus. Which medication should the nurse plan to provide this client? A) Indomethacin B) NSAIDS C) Antidepressant D) Insulin

Answer: A

The nurse is assessing a 24-year-old woman who recently found out she is pregnant. Which factor would the nurse identify as the most likely source of a barrier to health promotion in this client? A. Pregnancy occurred as a result of rape B. First pregnancy (primigravida) C. Presence of the client's mother during the appointment D. Age of the client

The nurse is caring for a client in a long-term care facility. The client has some cognitive impairment that interferes with the ability to independently complete activities of daily living. The nurse has identified Self-Care Deficit as an appropriate nursing diagnosis for this client. Based on this data, which expected outcome is the most appropriate for the nurse to include in the plan of care? A. The client, with supervision, will brush teeth twice per day. B. The client will be able to name the staff that works on the day shift. C. The client will eliminate safety hazards in the environment. D. The nurse will stress the importance of adequate fluid intake.

The nurse is providing teaching related to health promotion for a group of older adults. Several individuals describe their current health status. Which client is most in need of additional information related to health promotion? A. A client who states she was recently diagnosed with Parkinson disease B. A client who states that she walks five times a week at the community center to help prevent osteoporosis C. A client who states that her daughter takes her to all of her medical appointments D. A client who states that her husband has been suffering from hypertension for the past 12 years

While conducting a gait and posture assessment, the nurse becomes concerned and suspects that the patient has a herniated lumbar disc. Which assessment finding caused the nurse's suspicion? A. Flattened lumbar curve B. Presence of lordosis C. Convex thoracic spine D. Concave cervical spine

A A flattened lumbar curve and decreased spinal mobility may be evidence of a herniated lumbar disc. A concave cervical spine is an expected finding. A convex thoracic spine is also an expected finding. Lordosis is associated with pregnancy or obesity.

10) A nurse is caring for a client with hypothermia and frostbite of the nose and fingers. Which action by the nurse is inappropriate for this client? A) Massage frostbite areas to rewarm them and increase circulation. B) Rapidly rewarm affected areas in circulating warm water. C) Keep the client on bedrest with the affected parts elevated. D) Debride blisters

A A nurse should never massage frostbite areas, as this action will further damage necrotic tissue. All other choices are appropriate nursing interventions for a client with frostbite.

What are the differences among a STAT order, a prn order, and a standing order?

A STAT order refers to any medication that is needed immediately and is to be given only once. It is often associated with emergency medications that are needed for life-threatening situations and should be given within 30 minutes or less after being ordered. A PRN order (Latin: pro re nata) is administered as required by the client's condition. Nurses make judgments, based on client assessment, as to when such a medication is to be administered. A standing order is written in advance of a situation that is to be carried out under specific circumstances.

The family of a patient with limited mobility asks, "Why is our father not moving now? He moved well before." Which response from the nurse addresses the most likely cause of the patient's limited mobility? A. "Your father's limited mobility is likely due to pain." B. "Your father may have limited mobility because he is depressed." C. "Your father's inability to hear well may be limiting his mobility." D. "Your father's reduced flexibility is the likely cause of his limited mobility."

A Conditions that may limit mobility include pain, fatigue, respiratory disorders, cardiovascular disease, nervous system disorders, and musculoskeletal diseases or injuries. While immobility may lead to problems with depression, depression itself would not limit the patient's mobility. Lack of hearing also would not limit mobility. Joint flexibility encourages, not limits, mobility.

The nurse discusses scoliosis with a group of parents of school-age children. The nurse includes degrees of curvature of the spine in the discussion. Which curvature of the spine should the nurse include as being severe? A. A curve 40 degrees or greater B. A curve greater than 100 degrees C. A curve that affects other organs D. A curve between 20 and 40 degrees

A Curvatures are classified as severe at 40 degrees or greater. Between 20 and 40 degrees, they are classified as moderate. Organ involvement is not a classification criterion. Curvatures greater than 100 degrees are life-threatening.

The nurse is providing discharge teaching for a patient with an alteration of mobility. The family asks the nurse, "What is the best thing we can do to keep our father free from injury?" Which response by the nurse is appropriate? A. "Pick up all the throw rugs you have so your father doesn't fall." B. "Keep the lights turned down low." C. "Encourage your father to learn something new." D. "Avoid helping your father with things he can do for himself."

A Preventing injury is a goal for the patient with an alteration of mobility. The patient's environment should be screened for potential hazards like loose floor coverings. Lights should be kept at adequate levels so the patient can clearly see to move. Avoiding helping someone do what they can do for themselves and encouraging them to learn something new are interventions that foster independence, not protect the patient from injury.

The nurse is providing discharge teaching for a patient admitted for a back injury. The nurse instructs the patient on proper body mechanics for lifting. Which patient statement indicates that further teaching is needed? A. "I should bend my back when I pick up an object." B. "I should stand with my feet apart with one foot slightly ahead of the other." C. "I should stand close to the object that I am lifting." D. "I should use my feet to pivot to move the object."

A Proper body mechanics include bending at the knees, not at the back, when picking up an object. In addition, standing with feet apart and one foot in front of the other will provide balance when lifting. Standing close to the object to be lifted and lifting it straight up will prevent injury as will using the feet to pivot rather than twist and turn the back.

Which admission assessment is most appropriate for the nurse to perform for a patient with altered mobility? A. Observe as the patient walks across the room. B. Observe the patient eat a meal. C. Observe the patient interact with family. D. Observe the patient get undressed.

A The best way to assess mobility is to observe the patient walk across the room. The nurse should notice gait, balance, use of assistive devices, and any signs of pain. Observing the patient eat a meal, get undressed, and interact with family does not give enough information to determine degree of mobility.

Exemplar 20.2 Hypothermia 1) A client comes into the emergency department complaining of the inability to feel the hands and feet after waiting for 2 hours for transportation in 20°F weather. What should the nurse do to help this client? A) Warm the hands and feet in 104°F water for 20 to 30 minutes. B) Provide an antipyretic. C) Rub and massage the hands and feet. D) Warm the hands and feet in tepid water for 2 hours

A The client's inability to feel his hands and feet after spending 2 hours in 20°F weather would indicate the client is experiencing frostbite. Rapid thawing decreases tissue necrosis and should be done by warming the hands and feet in 104°F water for 20 to 30 minutes. The hands and feet should not be rubbed. Tepid water will not rapidly warm the hands and feet.

Exemplar 20.1 Hyperthermia 1) The mother of preschool-age client tells the nurse that the client has frequent fevers. What should the nurse respond to this mother? A) "Fevers are most frequently seen in children because of developing immunity." B) "This is unusual because common diseases of childhood rarely result in fevers." C) "Your child must be around people with illnesses." D) "Your child's immunity is compromised."

A The very young and the very old have diminishing immunity, which places them at risk for fevers. Fevers are most frequently seen in children because of developing immunity. The nurse has no way of knowing if the client's immunity is compromised. The child may or may not be around people with illnesses. Common diseases of childhood frequently result in fevers.

The nurse is performing a focused health history for a client diagnosed with a herniated disc. Which information is most appropriate for the nurse to include in this history? A. Work and recreational activities B. Diet recall C. Ethnicity D. Drug use

A Rationale: Frequent twisting and lifting are significant risk factors for herniated disc, so work and recreational activities should be assessed. Substance abuse, diet and nutrition, and genetic risk factors common to specific ethnicities can be important components of a health history but are not particularly pertinent to herniated discs.

A client with altered mobility reports gastric upset. Which medication should the nurse suspect is causing the client's symptoms? A. Nonsteroidal anti-inflammatory drug (NSAID) B. Direct-acting antispasmodic C. Skeletal muscle relaxant D. Bone growth stimulator

A Rationale: Side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) include gastric upset and bleeding. Central nervous system (CNS) effects are commonly caused by skeletal muscle relaxants. Bone growth stimulators may cause renal or liver impairment. Direct-acting antispasmodics may cause angina, difficulty breathing, and muscle weakness.

Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply. A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning D) Prescribing bronchodilators E) Monitoring activity intolerance

A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning E) Monitoring activity intolerance

A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning E) Monitoring activity intolerance Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.

The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply. A) Excessive rapid breathing B) Chest pain C) Rapid breathing at rest D) Shallow breathing E) Cyanosis

A) Excessive rapid breathing C) Rapid breathing at rest D) Shallow breathing

A) Excessive rapid breathing C) Rapid breathing at rest D) Shallow breathing Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.

Which practices support promotion of health safety? Select all that apply. A) Exercise every day B) Avoid driving when sleepy or tired C) Eliminate all foods containing fat D) Wear seat belts E) Only see healthcare providers when sick

A) Exercise every day B) Avoid driving when sleepy or tired D) Wear seat belts Health promotion involves many different practices, including staying physically active, following guidelines for motor vehicle safety, eating an appropriate diet, and monitoring personal health status. Eliminating all foods containing fat would eliminate necessary nutrients from the diet, and clients should see a healthcare provider at least annually for a checkup even if not sick.

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to address the client's ineffective breathing pattern? Select all that apply. A) Instruct in pursed-lip breathing B) Teach visualization and meditation C) Deep breathing and coughing every hour D) Instruct in abdominal breathing E) Provide oxygen 2 liters nasal cannula.

A) Instruct in pursed-lip breathing B) Teach visualization and meditation D) Instruct in abdominal breathing

The nurse is placing a newborn baby in the nursery crib with the baby's back down. The mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family members sleep on their stomachs. Which action by the nurse is appropriate? A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep. B) Place the baby on the stomach. C) Suggest the mother place the baby on the stomach when at home. D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care.

A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS) and it will not interfere with sleep.

How does a brainstem abnormality contribute to the risk of SIDS when an infant is placed on his stomach to sleep? A) It decreases the infant's arousal and head turning responses during times of asphyxia. B) It decreases the infant's respiratory drive during NREM sleep. C) It increases periods of apnea, resulting in hypoxia and unconsciousness. D) It increases the risk of aspiration and airway obstruction.

A) It decreases the infant's arousal and head turning responses during times of asphyxia.

Administering oxygen therapy with a nonrebreather mask has which of the following advantages? A) Offers the highest oxygen concentration of the low-flow systems B) Provides oxygen concentrations of 40% to 60% C) Incorporates a design that requires minimal monitoring of the patient D) Is designed for safety once the mask's valves and flaps are sealed

A) Offers the highest oxygen concentration of the low-flow systems

The nurse is planning care for a young adolescent client diagnosed with asthma. Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply. A) Referring to a peer-led support group B) Teaching the parents how to administer maintenance medication prior to teaching the client C) Assessing peer support when planning care D) Collaborating with teachers for support in the school setting E) Telling the client to avoid medication while at school

A) Referring to a peer-led support group C) Assessing peer support when planning care D) Collaborating with teachers for support in the school setting

While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply. A) Remove the suction catheter B) Lower the head of the bed C) Decrease the suction pressure D) Apply restraints to the client's arms and legs E) Hyperoxygenate the client

A) Remove the suction catheter C) Decrease the suction pressure E) Hyperoxygenate the client

A) Remove the suction catheter C) Decrease the suction pressure E) Hyperoxygenate the client The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.

A) Respiratory acidosis Both the pH and the carbon dioxide levels represent acidosis. The PaO2 of 82 is on the low end of normal and the bicarbonate level is normal, indicating that this is respiratory acidosis rather than metabolic acidosis.

A patient has been receiving oxygen PRN via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective? A) Respiratory rate 14/min B) SaO2 90% C) Cardiac output 5.6 L/min D) PaCO2 68 mm Hg

A) Respiratory rate 14/min

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which factors in the client's history support the current diagnosis? Select all that apply. A) Working in an industrial environment B) Working in an office setting with air conditioning C) History of asthma D) Current cigarette smoking E) Playing golf several times a week

A) Working in an industrial environment C) History of asthma D) Current cigarette smoking

The family of a client with mobility difficulties asks the nurse, "What age-related changes to the musculoskeletal system should we expect our father might experience?" Which change should the nurse include in the response? (Select all that apply.) A. Muscle fiber atrophy B. Ligament tears C. Increased bone density D. Decreased joint fluid E. Flexed position of hips

A, B, D, E Rationale: Changes in the musculoskeletal system that occur with aging include tears in ligaments, atrophy of muscle fibers, decreased joint fluid, and a flexed position of the hips. Bone density decreases with aging.

The nurse is conducting a health interview to determine a client's mobility status. Which lifestyle behavior is most appropriate for the nurse to assess? (Select all that apply.) A. Primarily working on a computer B. Living alone C. Long-distance running D. Smoking habits E. Taking no medications

A, C, D Rationale: A client's lifestyle affects mobility status. Smoking is a negative behavior that adversely affects many aspects of an individual's health. Physical activity such as long-distance running can affect the joints, ligaments, and cartilage. Computer work is a sedentary activity that could potentiate the development of musculoskeletal disorders. Living alone and not taking any medication would not adversely affect an individual's musculoskeletal or mobility status.

The nurse begins an early ambulation routine with a client diagnosed with altered mobility. Which benefit of early ambulation should the nurse explain to the client? (Select all that apply.) A. Strengthens muscles B. Improves skin turgor C. Improves self-esteem D. Reduces risk of thrombophlebitis E. Promotes diarrhea

A, C, D Rationale: Early ambulation decreases the risk of complications of inactivity, including thrombophlebitis, osteoporosis, muscle atrophy, constipation, and urinary incontinence. It also strengthens muscles, increases joint flexibility, stimulates circulation, and improves self-esteem. Ambulation does not promote diarrhea or improve skin turgor.

A pregnant client presents with back pain. Which condition is most likely the cause of this pain? (Select all that apply.) A. Stretched abdominal muscles B. Improper lifting C. Instability of the pelvis D. Bulging discs E. Strain from the growing uterus and fetus

A, C, E Rationale: Sixty-two percent of women report back pain during pregnancy. This pain is generally caused by strain on the back from the growing uterus and fetus, which causes postural changes; abdominal weakness from stretched abdominal muscles; and hormonal changes, which loosen the ligaments in the joints of the pelvis. Bulging discs and improper lifting do not normally cause back pain in pregnancy.

A client states, "My healthcare provider says my problem with mobility is with my connective tissues. What are connective tissues?" Which structure should the nurse include in the response? (Select all that apply.) A. Ligaments B. Muscle C. Bones D. Tendons E. Cartilage

A, D, E Rationale: Tendons, cartilage, and ligaments are all connective tissues. Tendons connect bone to muscle to cause movement. Cartilage is flexible connective tissue and is less flexible than muscle but not as stiff as bone. Ligaments connect bones to other bones to form a joint and serve to strengthen and stabilize the joint. Bones provide the framework for the skeletal structure. Muscles contain fibers that move the bones.

A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? A. "Get up and change positions slowly." B. "Avoid eating aged cheese and smoked meat." C. "Report any usual bruising or bleeding to the doctor immediately." D. "Eat the same amount of foods that contain vitamin K every day."

A. "Get up and change positions slowly." Rationale: A. Correct: Antihypertensive medications can cause orthostatic hypotension. The nurse should instruct the client to change positions slowly and to sit or lie down when feeling dizzy or lightheaded to prevent injury. B. Consuming foods that contain tyramine (avocados, figs, aged cheese, yeast extracts, beer, smoked meats) while taking monoamine oxidase inhibitors, not antihypertensives, can lead to hypertensive crisis. C. Clients taking an anticoagulant, not an antihypertensive, should report bruising, discolored urine or stool, petechiae, bleeding gums, and any other manifestations of bleeding to the provider immediately. D. Clients taking anticoagulants, not antihypertensives, should maintain a consistent intake of dietary vitamin K to avoid sudden fluctuations that could affect the action of the anticoagulant.

Order: Humulin regular insulin 6 units and Humulin NPH insulin 40 units, S.C., q.d. A. Explain the method for mixing the two insulins. B. How much regular insulin and how much NPH insulin you would withdraw. C. What are the unapproved abbreviations in the order? How should the order be written? Describe why these are unapproved abbreviations.

A. A. 40 units of Air in NPH, 6 units of Air in regular.; 2. Withdraw regular 6 units, Withdraw NPH 40 units. B. Total of 46 units in syringe. C. S.C., q.d. S.C should be written out as subcutaneous or subcut and q.d. should be written as daily. These abbreviations can cause harmful med errors due to misinterpretation. QD is a Joint Commission unapproved abbreviation and hospitals can be cited for using this abbreviation in the orders.

Write the full name for these abbreviations. A. Cap B. SR C. IM D. Subcut E. NPO F. ac/h.s. G. TID H. BID

A. Cap = capsule B. SR = slow release C. IM = intramuscular D. Subcut = subcutaneous E. NPO = nothing by mouth F. AC/Hour of sleep = before meals and at bedtime G. TID = three times a day H. BID= two times a day

Write out how you would say the following orders: A. Cefadyl 500 mg, IM, q6h B. Prednisone 5 mg, po, q8h x 5 days

A. Cefadyl 500 mg, IM, q6h - "I would give Cefadyl 500mg intramuscular every 6 hours." B. Prednisone 5 mg, po, q8h x 5 days - "Prednisone 5mg by mouth every 8 hours for 5 days"

Which is an effective nonpharmacologic therapy for impaired perfusion in the lower extremities? A. Compression stockings B. Orthopedic shoes C. Sitting with both feet on the floor D. Ventricular assist device

A. Compression stockings Rationale: Impaired perfusion in the lower extremities is often treated with compression stockings. Compression stockings are worn to prevent pooling of blood in the veins of the lower extremities. Blood can pool when venous blood return is not efficient. The collected blood can form clots that can dislodge and travel to the lungs, resulting in pulmonary embolism, or to the brain, resulting in stroke.

Order: Narcan 0.2 mg, IM, stat. A. How many milliliters of Narcan would you give? B. Can you refrigerate the unused portion of the vial of Narcan?

A. Give 0.5 ml of Narcan. B. Yes, a vial of drug can be saved and/or refrigerated; check drug circular. Should not be brought into a patient's room since this is a multidose vial. Most multidose vials can be used for up to 28 days. Make sure you label the vial after you open it and put the time and date when you opened it.

The nurse is working with a family that is new to the pediatric practice. In reviewing the family's records, the nurse notes that the older children have a large number of dental caries. Which topics will the nurse include when teaching the mother how to decrease the development of dental caries in infants? Select all that apply. A. Wiping the infant's gums with soft moist gauze once or twice daily B. Refraining from giving the infant a bottle for a prolonged time at bedtime C. Using a toothbrush as soon as the first tooth erupts D. Giving the infant sugar water only at breakfast time E. Using a topical anesthetic daily, beginning as soon as the first tooth begins to erupt

A parent of an adolescent client expressed concern to the nurse regarding the adolescent's sleeping habits. The parent states that the client wants to sleep all the time. The nurse believes that the adolescent is experiencing sleep deprivation. During the assessment, which clinical manifestations support this diagnosis? Select all that apply. A. Trouble initiating or persisting in projects, such as school assignments B. Difficulty waking in the morning for school C. Consumption of caffeinated soda D. Irritability and anxiety, especially on days with less sleep E. Refusal to participate in sports activities

ABCD

A nurse is preparing a workshop on the topics that are new to Healthy People 2020. Which of the topic areas should the nurse plan to address? Select all that apply. A. Lesbian, Gay, Bisexual, and Transgender Health B. Adolescent Health C. Mental Health and Mental Disorders D. Genomics E. Healthcare-Associated Infections

ABDE

The nurse is caring for a 34-year-old client who is about to be discharged from the hospital. The client asks the nurse for suggestions on how to improve the quality of sleep in order to wake feeling refreshed in the morning. After reviewing the client's medical history, which suggestions by the nurse are appropriate? Select all that apply. A. Limiting the use of alcohol to early in the evening B. Limiting cigarette smoking before bedtime C. Having a cup of tea before bed in order to enhance relaxation D. Changing the time of aerobic exercise to 1 hour prior to sleep E. Adjusting the room temperature to a comfortable level for sleep

ABE

Which nursing intervention exemplifies the nurse working in a health promotion role? Select all that apply. A. Reinforcing desirable changes to the client's lifestyle B. Administering a prescribed antibiotic C. Administering vaccines to a well child D. Obtaining a blood glucose sample on a client with hypoglycemia E. Administering an inhaler to a client with asthma

A nurse is providing wellness teaching to a client who is interested in beginning an exercise program to reduce certain health risks. The nurse determines that the client understands the teaching when the client selects which health risks that can be reduced by regular exercise? Select all that apply. A. Falling B. Renal disease C. Cardiovascular disease D. Type 2 diabetes E. Liver disease

ACD

An occupational health nurse for a large corporation is planning programs to address health problems identified in the Healthy People 2020 report. Which programs should the nurse include for the company employees at the worksite? Select all that apply. A. A seminar about the components of wellness B. An informational program about genomics C. An education program about the importance of sleep health D. A blood disorder and blood safety education program E. A cultural competence program related to LGBT health

ACDE

The pulmonary rehabilitation nurse is teaching a group of clients about both isotonic and isometric exercises. At the conclusion of the session, which client statements indicate effective teaching has occurred? Select all that apply. A. "Isometric exercises are useful for endurance training." B. "Isotonic exercises produce a mild increase in heart rate and cardiac output, but no appreciable increase in blood flow to other parts of the body." C. "Isotonic exercises are also called dynamic exercises." D. "Isotonic exercises are static movements." E. "Isometric exercises involve exerting pressure against a solid object."

ACE

10) A nurse is performing an assessment on a client diagnosed with aortic stenosis. The nurse will hear the client's murmur best at: A) Right sternal border, second intercostal space. B) Left sternal border, second intercostal space. C) Right sternal border, third intercostal space. D) Left sternal border, third to fifth intercostal space.

Answer: A

11) A nurse is caring for a client with cardiomyopathy who has a nursing diagnosis of Activity Intolerance. The nurse plans all interventions except: A) Spacing out nursing activities so client fatigue is lessened. B) Assisting with client ADLs as necessary. C) Using passive and active range-of-motion (ROM) exercises as tolerated. D) Consulting with a physical therapist on an activity plan.

Answer: A

A nurse is caring for a client who has a new prescription for a drug. After receiving the first dose of the drug, the client experiences anaphylaxis. The nurse should identify that anaphylaxis represents which of the following results of the drug? [] adverse effect [] paradoxical effect [] therapeutic effect [] toxicity

Adverse effect is correct Adverse effects are the unintended and unexpected effects of a drug, which can range from mildly annoying to life-threatening, such as an anaphylactic reaction. Paradoxical effect Paradoxical effects are the opposite of the intended or desired effect of a drug, such as a drug intended to aid with sedation causing increased excitability in certain clients. Therapeutic effect A therapeutic effect is the intended benefit of the drug for the client. Toxicity Toxicity occurs when the client receives a drug in excessive dosages. Manifestations of toxicity differ between drugs.

Why do errors continue to occur despite the fact that the nurse follows the five rights and three checks of drug administration?

Although the nurse is responsible for safe medication administration, errors continue because many disciplines are responsible for safe and accurate drug administration. Many steps are involved in the safe administration of medications, and there are multiple points where errors can occur.

11) A physician caring for a client with hypoplastic left heart syndrome has provided the client's family with information regarding the surgical repair necessary for this condition. The client's nurse knows that this procedure is named the: A) Glenn procedure. B) Jatene procedure. C) Fontan procedure. D) Damus-Kaye-Stansel procedure.

Answer: A

3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be indicated for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids

Answer: A

Which of the following should a nurse assess before administering medications through a nasogastric tube? Correct tube placement by inserting air into tube while auscultating at gastric fundus Areas of tympany and dullness by percussing abdomen Amount of residual volume left in stomach Ability of patient to cooperate with instructions

Amount of residual volume left in stomach

Which of the following represents the correct administration of the prescribed medication? -Acetaminophen 650 mg PO prescribed 5 tsp of 325 mg/10mL liquid given -Levothyroxine 100mcg PO prescribed; three 0.025 mg tablets given -Amoxicillin 1 g PO prescribed,: two 500-mg tablets given -Diphenhydramine 40 mg IM prescribed: 1.25 mL of 50 mg/1 mL for injections given

Amoxicillin 1 g PO prescribed: two 500-mg tablets given

A primary health-care provider prescribes crutches for a person who has a left lower leg injury. The nurse is teaching the person how to move from a standing to a sitting position in a chair. Place the following steps in the order in which they should be implemented. 1. While standing, back up so that the unaffected leg is against the edge of the center of the chair seat. 2. Hold the hand bars of both crutches with the left hand. 3. Lean forward slightly and flex the knees and hips. 4. Grasp the arm of the chair with the right hand. 5. Lower the body slowly into the chair.

Answer: 1, 2, 4, 3, 5 Rationale: 1. Being as close as possible to the chair allows a person to use the chair for support when sitting. Also, it supports sitting deeper into the seat of the chair, which is safer than sitting on the edge of the seat. 2. Holding the hand bars of both crutches with the left hand frees the right hand for the next step in the procedure. 3. Leaning forward slightly and flexing the knees and hips partially lowers the body and prepares it for the next step in the procedure. 4. Grasping the arm of the chair with the right hand allows the person to support body weight partially on the right arm and the right leg. 5. Lowering the body slowly into the chair protects the body from injury.

A primary health-care provider prescribes a medication cream for a client to be administered topically to an area of excoriated skin. Place the following steps in the order in which they should be implemented. 1. Don clean gloves 2. Evaluate the results of the cream on the skin 3. Warm the tube of medication before administration 4. Cleanse the skin gently with soap and water and pat dry 5. Don sterile gloves and apply a thin layer of cream to the desired area

Answer: 1, 4, 3, 5, 2 1. Using clean gloves conforms to standard precautions; they protect the nurse from the client's body fluids. 2. Evaluating the results of the cream on the skin ensures that therapeutic and nontherapeutic responses to the medication are identified. These responses must be documented and communicated to other members of the heath-care team. 3. Warming the medication promotes the comfort for the client when it is applied. 4. Cleansing the area removes debris and previously applied topical medication; doing so allows the skin to be accessible to the cream. Patting the skin dry is less irritating to the skin than rubbing, and the dry surface facilitates adherence of the cream. 5. Sterile gloves maintain sterility of the procedure and prevent the nurse from contacting and absorbing the medication. excessive cream can irritate the skin.

A primary health-care provider prescribes NPH and regular insulin to be administered to a client with diabetes. Place the following actions in the order in which they would be implemented when mixing NPH and regular insulin in the same syringe. 1. Inject air into regular insulin 2. Inject air into NPH insulin 3. Withdraw dose from regular insulin 4. Withdraw dose from NPH insulin

Answer: 2, 1, 3, 4 1. The nurse should inject the remaining air into the air pocket of the regular insulin vial while the vial is right-side up. Keeping the needle in the air pocket avoids causing bubbles in the solution. Bubble displace solution, increasing the risk of an incorrect dose. Also, the injected air prevents negative pressure inside the regular insulin vial later when withdrawing the regular insulin. 2. The nurse should use an insulin syringe to draw up environmental air equal to the combined volume of both insulins. While keeping the NPH vial right-side up, the nurse should inject air equal to the prescribed amount of NPH into the air pocket at the top of the vial. This air prevents negative pressure inside the NPH vial when the NPH solution is withdrawn later in the procedure. Injecting air into the air pocket at the top of the vial avoids needle exposure to the NPH insulin and prevents bubbles that later can cause an inaccurate dose when the NPH insulin is withdrawn. 3. The nurse should invert the regular insulin vial and draw up the prescribed amount of regular insulin. By drawing up the regular insulin first, it prevents contamination of the regular insulin vial with NPH insulin, which is slower acting. 4. The nurse should reinsert the needle into the NPH vial, invert the vial, and withdraw the prescribed amount of NPH insulin. The mixed insulin is now ready to be administered.

A primary health-care provider prescribes a vaginal suppository for a client. The nurse obtains the suppository, pulls the curtain around the client's bed, encourages the client to void, provides perineal care, and then dons a new pair of clean gloves. Place the following steps in the order in which they should now progress to complete the administration of the vaginal suppository. 1. Drape the client, exposing only the vaginal area 2. Position the client in the dorsal recumbent position 3. Encourage the client to remain in the supine position for 10 to 20 minutes 4. Lubricate the suppository and the nurse's index finger with a water-soluble jelly 5. Insert the suppository downward and backward using the full length of the index finger

Answer: 2, 1, 4, 5, 3 1. Exposing only the vaginal area provides for privacy and supports dignity. 2. Positioning the client in the dorsal recumbent position provides access to the vaginal area and is a comfortable position for the client during the procedure. 3. Encouraging the client to remain in the supine position for 10 to 20 minutes after insertion allows time for the suppository to melt and to keep it in contact with vaginal tissue, which facilitate absorption. 4. Lubricating the suppository and the nurse's gloved index finger facilitates insertion and limits tissue trauma. A water-soluble jelly is gentle and soothing to the mucous membranes of the vagina. 5. Directing insertion downward and backward using the full length of the nurse's index finger follows the contour of the vaginal anatomy and ensures that the medication is inserted deep in the vaginal canal.

A nurse is to transfer a client from a bed to a chair. After washing the hands, providing privacy, and explaining the transfer to the client, the nurse ensures that the wheels on the bed are locked and moves the bed to the lowest position. Place the following steps in the order in which they should be implemented. 1. Verify if the client feels dizzy. 2. Assess the client's vital signs and strength while in the supine position. 3. Assist the client to a sitting position on the side of the bed, with the feet on the floor. 4. Elevate the head of the bed to the high-Fowler position and put footwear on the client's feet. 5. Support the client sitting on the side of the bed for several minutes before transferring to a chair.

Answer: 2, 4, 3, 1, 5 Rationale: 1. Verifying if the client feels dizzy evaluates tolerance to the activity and is the fourth step in the transfer procedure. Dizziness indicates orthostatic hypotension. If dizziness occurs, the nurse should support the client in the sitting position for a few minutes. if dizziness does not resolve, then return the client to a semi-Fowler position to provide for the safety of the client. 2. Assessing vital signs is the first step in the procedure because results provide baseline data against which to compare outcomes when evaluating activity tolerance. 3. Assisting the client to a sitting position on the side of the bed, with the client's feet on the floor, facilitates pivoting of the trunk of the body perpendicular to the length of the bed. This prepares the body eventually to assume a wide base of support, with the greatest mass between the feet. 4. Elevating the head of the bed is the second step in the procedure. It minimize the effort required by the client to move to a sitting position in the bed as well as minimizes lifting by the nurse. Footwear protects the client's feet from physical injury and contamination from pathogens that may be on the floor. 5. Supporting the client in the sitting position for several minutes before transferring to a chair is the fifth step in the transfer procedure. This reduces the possibility of orthostatic hypotension and allows more time for an evaluation of the client's response to the change in position.

A nurse teaching a preoperative client how to use an incentive spirometer. Place the following steps of the use of an incentive spirometer in the order in which they should be performed. 1. Inhale slowly. 2. Hold the incentive spirometer level. 3. Remove the mouthpiece and exhale normally. 4. Keep the visual indicator at the inspiratory goal for several seconds. 5. Maintain a firm seal, with the lips around the mouthpiece during inhalation.

Answer: 2, 5, 1, 4, 3 1. Inspiration should be accomplished through a slow, deep breath. A rapid, forceful inhalation can collapse the airway and is contraindicated. 2. Holding the incentive spirometer level prevents factors, such as friction and gravity, from altering the correct function of the device. 3. Each exhalation should be an unforced, normal exhalation. A seal does not need to be maintained around the mouthpiece. 4. When the visual indicator reaches the present goal during inhalation, the inhalation should be maintained for 2 to 6 seconds to ensure ventilation of the alveoli. 5. A firm seal around the mouthpiece is necessary during inhalation, but the mouthpiece should be removed during exhalation.

A primary health-care provider prescribes a medication via a transdermal patch. Place the following steps in the order in which they should be implemented when administering this medication. 1. Remove the previous patch 2. Contain and dispose of the used patch 3. Wear clean gloves throughout the procedure 4. Write the date, time, and your initials on the patch 5. Apply a new patch to a different section of the skin 6. Wash and dry the skin after removal of the used patch

Answer: 3, 1, 2, 6, 5, 4 1. Removing the previous patch reduces the risk of an overdose of the medication. 2. Containing and disposing of the used patch protects others from contact with active matter on the patch. 3. Wearing clean gloves protects the nurse from contact with the medication. 4. Writing the date, time, and your initials on the patch allows for accountability and helps minimize the risk of a medication error. 5. Applying a patch to a different surface of the skin avoids irritation to a surface that is used excessively. 6. Washing and drying the skin after removing a used patch eliminates lingering medication from the skin and minimizes the risk of overdose.

A nurse in a subacute unit in a skilled nursing facility is caring for a client who recently had the surgical creation of a colostomy. Place the following nursing actions in the order the reflects the nurse-client therapeutic relationship, beginning with the first stage and progressing to the last stage. 1. Provide positive feedback to the client for successful performance of a colostomy irrigation. 2. Assist the client to learn how to perform colostomy self-care. 3. Review all the information on the client's clinical record. 4. Explore the reasons for the nurse-client interactions. 5. Summarize the goals and objectives achieved. 6. Introduce self to the client.

Answer: 3, 6, 4, 2, 1, 5 Rationale: 1. During the working stage of the nurse-client therapeutic relationship, the nurse provides feedback about the client's performance. 2. During the working stage of the nurse-client therapeutic relationship, the nurse and client work toward meeting the client's needs. The nurse may function as a caregiver, counselor, teacher, resource person, etc. 3. During the preinteraction stage of the nurse-client therapeutic relationship, the nurse gathers information about the client. This stage occurs before meeting the client. 4. During the orientation stage of the nurse-client therapeutic relationship, the nurse and the client exchange information, clarify roles, and identify goals and objectives of the interaction. 5. During the termination stage of the nurse-client therapeutic relationship, the nurse summarizes what has been accomplished, reinforces past learning, arranges for available resources, and concludes the interpersonal relationship. 6. During the orientation stage of the nurse-client therapeutic relationship, the nurse introduces himself or herself to the client and begins to establish a rapport with the client.

A primary health-care provider prescribes oxygen via a simple face mask at a flow rate of six liters for a client. The nurse explains the procedure to the client and maintains standard precautions. Place the following steps in the order in which they should be implemented 1. Place the mask on the client's face from the bridge of the nose to under the chin. 2. Secure the elastic bands around the back of the client's head. 3. Attach the prefilled humidifier to the flowmeter. 4. Attach the flowmeter to the wall oxygen source. 5. Attach the face mask tubing to the humidifier. 6. Turn the oxygen flowmeter on to six liters.

Answer: 4, 3, 5, 6, 1, 2 1. The fifth step is placing the mask on the client's face. Applying it from the bridge of the client's nose to under the chin limits oxygen from leaking around the edges of the mask. 2. The sixth step is securing the elastic bands around the back of the client's head. This helps to hold the mask in position. 3. The second step is to attach the prefilled humidifier to the flowmeter. Humidification reduces drying of the respiratory system mucous membranes and is essential when oxygen delivery is 4 L or higher. 4. The first step is to attach the flowmeter to the wall oxygen source. The flowmeter controls the amount of oxygen delivered. 5. The third step is attaching the mask's tubing to the humidifier. This prepares the equipment for use. 6. The fourth step is turning on the oxygen flow rate to 6 L. This primes the tubing and mask with oxygen so that there is no delay once the mask is applied to the client's face.

A primary health-care provider prescribes medicated eardrops for a client. Place the following steps in the order in which they should be implemented after cleaning the client's ear. 1. Release the pinna and gently press on the tragus several times 2. Pull up and back on the cartilaginous part of the pinna gently 3. Place the drops on the side of the ear canal without touching the canal with the dropper 4. Position the client in the side-lying position with the affected ear facing toward the ceiling 5. Warm the refrigerated eardrops to room temperature by holding the container in the palm of a hand for several minutes

Answer: 5, 4, 2, 3, 1 1. Pressing gently on the tragus several times moves the medication along the external ear canal toward the tympanic membrane. 2. Gently pulling up and back on the pinna for an adult helps to straighten the ear canal, and this promotes the flow of drops toward the tympanic membrane. 3. Placing the drops on the side of the ear canal allows the fluid to flow down the wall of the external ear canal and avoid injury to the tympanic membrane. 4. The side-lying position helps to retain the drops in the external ear canal via gravity. 5. Warming the medication to room temperature minimizes discomfort when the medication enters the external ear canal.

9) A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute. What is the client's cardiac output (CO) rounded to the nearest whole number?

Answer: 6 Liters (L)

1) The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. About what should the nurse ask the mother during the assessment? A) Use of alcohol during the pregnancy B) Maternal father's history of diabetes C) Father's exposure to toxins in the work environment D) History of hypertension

Answer: A

A patient is being evaluated for the source of a productive cough and shortness of breath. Which diagnostic test should the nurse expect to be ordered first? A. Sputum specimen B. Thoracentesis C. Pulmonary function test (PFT) D. Bronchoscopy

Answer: A A sputum specimen is expectorant matter that may contain mucus, cellular debris, blood, microorganisms, or purulent matter from the respiratory tract that can help identify infection and inflammation. This test is ordered first. Bronchoscopy is an invasive procedure and would not be used first for diagnosis of a productive cough. Thoracentesis is used to remove fluid from the pleural space. It is invasive and not directly linked to productive cough. PFT is used to measure changes in lung function, but it is not used to diagnose a productive cough.

A nurse must administer a medication that is supplied in an ampule. Which should the nurse do first to access the ampule? A. Break the constricted neck using a barrier B. Wipe the constricted neck with an alcohol swab C. Insert the needle into the center of the rubber seal D. Inject the same amount of air as the fluid to be removed

Answer: A A. A barrier, such as a commerically manufactured ampule opener, gauze, or an alcohol swab, should be used to protect the nurse's hands from broken glass. B. The rubber seal of a vial, not the neck of an ampule, should be wiped with alcohol. C. Piercing a rubber seal is done with a vial, not an ampule. D. Injecting air is done with a vial, not an ampule.

Which outcome best reflects achievement of the goal, "The client will expectorate lung secretions with no signs of respiratory complications"? A. Absence of adventitious breaths sounds B. Deep breathing and coughing nonproductively C. Drinking 3,000 mL of fluid in the last 24 hours D. Expectorating sputum three times between 3 p.m. and 11 p.m.

Answer: A A. Adventitious breath sounds are abnormal breath sounds that occur when pleural linings are inflamed or when air passes through narrowed airways or through airways filled with fluid. The absence of abnormal sounds is desirable. B. To expectorate secretions, coughing must be productive, not nonproductive. A nonproductive cough is dry, which means that no respiratory secretions are raised and spat out (expectorated) because of coughing. C. Drinking fluid is an intervention that will liquefy respiratory secretions, thus facilitating their expectoration. However, just drinking fluid will not ensure that the secretions will be expectorated. D. Although spitting out sputum reflects achievement of the goal in relation to expectorating lung secretions, it does not address the absence of respiratory complications, which is the ultimate goal of decreasing stasis of respiratory secretions.

Which route is inappropriate for a topical medication? A. Intradermal B. Bladder C. Rectum D. Vagina

Answer: A A. An intradermal injection is inserted below, not on top of, the epidermis. B. Medications in the form of solutions can be instilled into the bladder. They are designed to work locally and are considered topical medications. C. Medications in the form of a suppository can be inserted into the rectum and are considered topical medications. Most are designed to work locally, although some are absorbed systemically. D. Medications in the form of a suppository, tablet, cream, forma, or jelly can be instilled into the vagina. They are designed to work locally and are considered topical medications.

A nurse is teaching a client how to use an incentive spirometer. Which position should the nurse assist the client to assume during this procedure? A. Sitting B. Side-lying C. Orthopneic D. Low-Fowler

Answer: A A. An upright sitting position in a bed or a chair facilitates maximum thoracic excursion because it permits the diaphragm to contract without pressure being exerted against it by abdominal viscera. B. The side-lying position is not ideal for the use of an incentive spirometer because it limits thoracic expansion. The side-lying position allows abdominal viscera to exert pressure against the diaphragm during inspiration, and the lung on the lower side of the body is compressed by the weight of the body. C. Although the orthopneic position allows for thoracic expansion, leaning forward with the arms on an over-bed table does not free the hands for holding the spirometer. D. The low-Fowler position does not maximize the effects of gravity. In the high-Fowler position, gravity moves abdominal viscera away from the diaphragm and thus facilitates the contraction of the diaphragm, both of which promote thoracic expansion.

A primary health-care provider prescribes bedrest for a client. Which should the nurse explain to the client is the primary purpose of bedrest? A. Conserve energy. B. Maintain strength. C. Enhance protein synthesis. D. Reduce intestinal peristalsis.

Answer: A A. Bedrest reduces cardiopulmonary demands, muscle contraction, and other bodily functions. All of this reduces the basal metabolic rate, which conserves energy. B. Activity, not bedrest, maintains strength. C. Protein synthesis is enhanced by the intake of amino acids, not bedrest. D. Although bedrest may limit peristalsis, it is not the most common reason bedrest is prescribed.

Answer: A A. Correct: The client should flush the tubing before and after each medication with 15 to 30 mL water to prevent clogging of the tube. B. To maximize the therapeutic effect of a medication, the client should not mix medications with enteral formula. In addition, if the client does not receive the entire feeding, he does not receive the entire medication. This can also delay the client receiving the medication. C. The client should not administer tablets or undissolved medications through a jejunostomy tube because they can clog the tube. D. The client should self-administer each medication separately.

A nurse prepares an injection or morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? A. Offer to assist the client who needs the bedpan. B. Administer the injection the other nurse prepared. C. Prepare another syringe and administer the injection. D. Tell the client who needs the bedpan she will have to wait for her nurse.

Answer: A A. Correct: The second nurse should offer to assist the client who needs the bedpan. This will allow the nurse who prepared the injection to administer it. B. A nurse should only administer medications that she prepared. C. Preparing another syringe will delay the administration of the pain medication. D. Telling the client to wait is not an acceptable option for a client who needs a bedpan.

A nurse must administer a medication into the ear of an adult. Which should the nurse do to limit client discomfort when administering the eardrops? A. Warm the solution to body temperature B. Place the client in a comfortable position C. Pull the pinna of the ear upward and backward D. Instill the fluid in the center of the auditory canal

Answer: A A. Instilling cold medication into the ear canal is uncomfortable and can cause vertigo and nausea. Holding the bottle of medication in the hand for several minutes warms the solution to body temperature. B. A comfortable position may not be the side-lying position, which is required for administration of an ear drop. The side-lying position with the involved ear upward must be maintained for 2 to 3 minutes while the instilled medication disperses throughout the ear canal. C. These actions straighten the ear canal and facilitate the flow of medication toward the eardrum in an adult; they do not limit discomfort. D. This action is contraindicated because the force of the fluid may injure the eardrum. The drops should be directed along the side of the ear canal.

A nurse is reviewing the laboratory results of a client with the preliminary diagnosis of anemia. An abnormal response of which diagnostic test would reflect iron-deficiency anemia? A. Hemoglobin B. Platelet count C. Serum albumin D. Blood urea nitrogen

Answer: A A. Iron is necessary for hemoglobin synthesis. Therefore, reduced intake of dietary iron results in iron-deficiency anemia. Hemoglobin is the main component of red blood cells and transports oxygen and carbon dioxide through the bloodstream. B. Platelets are unrelated to iron-deficiency anemia. Platelets (thrombocytes) are non-nucleated, round or oval, flattened, disk-shaped, formed elements in the blood that are necessary for blood clotting. C. Albumin is unrelated to iron-deficiency anemia. Albumin is a protein in the blood that helps to maintain blood volume and blood pressure. D. Blood urea nitrogen (BUN) is unrelated to iron-deficiency anemia. BUN is a test that measures the nitrogen portion of urea present in the blood. It is an index of glomerular function in the production and excretion of urea.

A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. Which is the rationale for this action? A Prevent soiling of the label by spilled liquid B. Conceal the label from the curiosity of others C. Ensure accuracy of the measurement of the dose D. Guarantee the label is read before pouring the liquid

Answer: A A. Liquid medication may drip down the side of the bottle and soil the label, which may interfere with the ability to read the label accurately. B. Although client confidentiality should always be maintained, this is not the reason for holding the label toward the palm of the hand. C. Accuracy of the dose is ensured by using a calibrated cup and measuring the liquid at the base of the meniscus while positioning the cup at eye level. D. The label should be read before holding it against the palm of the hand.

A nurse is assessing a postoperative client. Which complication has occurred when the client experiences purulent sputum, dyspnea, and chest pain? A. Hypostatic pneumonia B. Hypovolemic shock C. Thrombophlebitis D. Pneumothorax

Answer: A A. Postoperative clients often experience hypoventilation, immobility, and ineffective coughing that may lead to stasis of respiratory secretions and the multiplication of microorganisms, causing hypostatic pneumonia. Dyspnea results from decreased lung compliance, chest pain results from coughing and the increased work of breathing, and purulent sputum results from the presence of pathogens. B. Hypovolemic shock is characterized by tachycardia, tachypnea, and hypotension. C. Thrombophlebitis is characterized by localized pain, swelling, warmth, and erythema. If a thrombus breaks loose and travels through the venous circulation to the lung (pulmonary embolus), it will cause dyspnea and chest pain, not purulent sputum. D. Pneumothorax is characterized by a sudden onset of sharp pain on inspiration, dyspnea, tachycardia, and hypotension.

A nurse raises the head of the bed for a client who has difficulty breathing. Which science includes the principle that explains how this intervention facilitates respiration? A. Physics B. Biology C. Anatomy D. Chemistry

Answer: A A. Raising the head of the bed drops the abdominal organs away from the diaphragm via the principle of gravity, facilitating breathing. Gravity, the tendency of weight to be pulled toward the center of the earth, is a physics principle. B. Raising the head of the bed is not related to biology. Biology is the study of living organisms. C. Raising the head of the bed is not related to anatomy. Anatomy is the study of the form and structure of living organisms. D. Raising the head of the bed is not related to chemistry. Chemistry is the study of elements, compounds, and atomic relations of matter.

When the nurse brings a pill to a client, the client is unable to hold the paper cup with the medication. Which should the nurse do? A. Use the cup to introduce the pill into the client's mouth B. Crush the pill and mix it with a small amount of applesauce C. Have the primary health-care provider prescribe the liquid form of the drug D. Put the pill into the client's hand and have the client self-administer the pill

Answer: A A. The client needs assistance. keeping medication in the cup, rather than touching it with the hands, maintains medical asepsis. B. Mixing medication with applesauce is done if the client has dysphagia. C. It is not necessary to obtain a prescription for the liquid form of the medication. A prescription is required if a route other than oral is necessary. D. This action is unrealistic and unsafe. The client requires assistance.

A nurse plans to administer a 3-mL intramuscular injection. Which muscle is the least desirable to use for the administration of this medication? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis

Answer: A A. The deltoid muscle, on the lateral aspect of the upper arm, is a small muscle that is incapable of absorbing a large medication volume. This site is more appropriate for 1 mL of solution. B. The dorsogluteal site uses the gluteus maximus muscles in the buttocks, which can absorb larger medication volumes. C. The ventrogluteal site uses the gluteus medius and minimus muscles in the area of the hip, which can absorb larger medication volumes. D. The vastus lateralis muscles are located on the anterolateral aspect of the thighs, which can absorb larger medication volumes.

A nurse is evaluating an ambulating client's balance. Which factor about the client is most important for the nurse to assess? A. Posture B. Strength C. Energy level D. Respiratory rate

Answer: A Rationale: A. Assessing posture will identify whether the client's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and therefore balanced within the client's base of support. B. Strength has more to do with the exertion of power, not balance. C. Energy has more to do with endurance, not balance. D. Assessing the respiratory rate before activity establishes a baseline against which to compare the respiratory rate after activity to determine tolerance for activity, not balance.

A nurse is preparing to reconstitute a medication in a multiple-dose vial. Which is the most essential step in the preparation of this medication? A. Instilling an accurate amount of diluent into the vial B. Using a filtered needle when drawing up the medication from the vial C. Instilling air into the vial before withdrawing the reconstituted solution D. Wiping the rubber seal of the vial with alcohol before and after each needle insertion

Answer: A A. The required amount of diluent must be followed exactly in a multiple-dose formulation to ensure accurate dosage preparation. The diluent for a single-dose formulation also must be measured exactly so that the medication is diluted enough not to injure body tissues. B. A filtered needle should be used when drawing up fluid from an ampule, not a vial. A filter prevents shards of glass from entering the syringe. C. Although this is an advisable practice, it is not as important as administering an accurate dose. D. The rubber seal must be wiped with alcohol before, not after, needle insertion.

A nurse is preparing to draw up medication from a vial. Which action should the nurse implement first? A. Ensure that the needle is firmly attached to the syringe B. Rub vigorously back and forth over the rubber cap with an alcohol swab C. Inject air into the vial with the needle bevel before the surface of the medication D. Instill slightly more air than the volume of medication to be withdrawn from the vial

Answer: A A. This will ensure a tight seal and a closed system. If not firmly connected, the hub of the needle may disengage from the barrel of the syringe during preparation or administration of the medication where internal and external pressure are exerted on the needle and syringe. B. The top just needs to be swiped. Rubbing back and forth is a violation of surgical asepsis because it reintroduces microorganisms to the area being cleaned. C. Injecting air below the surface of the solution should be avoided because it causes bubbles that may interfere with the drawing up of an accurate volume of solution. D. Excess air in the closed system raises pressure in the vial that may cause bubbles when withdrawing the fluid and result in an inaccurate volume of solution.

Which nursing assessment best indicates a client's ability to tolerate activity? A. Vital signs that take three minutes to return to preactivity level B. Absence of adventitious breath sounds on auscultation C. Flexibility of both muscles and joints D. Reports of weakness after activity

Answer: A A. Vital signs reflect cardiopulmonary functioning of the body. Vital signs obtained before and after activity provide data that can be compared to determine the body's response to the energy demands of ambulation. When the vital signs return to the preactivity level within 3 minutes, it indicates that the client has tolerated the activity. B. The absence of abnormal breath sounds (adventitious sounds) indicates the nonexistence of a respiratory problem. Adventitious breath sounds (e.g., wheezes, rhonchi, rales, pleural friction rub, and stridor) indicate narrowed airways, presence of excessive respiratory secretions, pleural inflammation, or diminished ventilation and are not the best signs to use when assessing a person's tolerance to activity. C. Flexibility relates to mobility, not one's physiological capacity to endure activities that require energy. D. A report of weakness indicates that the client has not tolerated the activity.

While teaching parents about toy safety, a parent asks the nurse why their toddler is not able to play with their 10-year-old sibling's toys. Which explanation should the nurse provide? A. "Due to children's narrower airways, toddlers are at risk for airway obstruction." B. "Toddlers' ribs are less flexible and may impede their ability to cough and clear their airway." C. "Toddlers have more alveoli that require more air to move through the lungs." D. "Toddlers have lymph tissue that has atrophied and can lead to airway obstruction."

Answer: A Due to their narrower airways, toddlers are at risk for airway obstruction. Young children have more flexible ribs, not less flexible. Young children have a decreased, not increased, number of alveoli. Toddlers have increased lymph tissue that atrophies after age 12.

The nurse is auscultating tracheal sounds of a patient. Which sound should the nurse recognize as a normal finding? A. Harsh, high-pitched sound B. Soft, low-pitched sound C. Sound that is medium in loudness and pitch D. Loud, high-pitched sound

Answer: A Harsh, high-pitched sounds are normal sounds heard over the trachea when the patient inhales and exhales. Bronchovesicular sounds are medium in loudness and pitch, and they are heard between the scapulae, posteriorly and next to the sternum. Vesicular sounds are soft and low pitched, and they are heard over the remainder of the lung. Vesicular sounds are longer on inhalation than exhalation. Bronchial sounds are loud, high-pitched sounds next to the trachea.

The nurse is teaching patients at risk for impaired perfusion about a heart-healthy lifestyle. Which modification would be most appropriate for this group? A. Maintain normal body weight. B. Exercise one to three times per week for 15 minutes per session. C. Limit alcohol consumption to no more than 8 oz per day. D. Cut back on smoking by half of the current amount.

Answer: A Maintaining a body mass index (BMI) below 25 helps reduce the risk of coronary artery disease. Normal BMI and proper diet can also affect serum lipids. Both childhood and adult obesity can predispose individuals to hypertension. A 10-lb weight loss reduces blood pressure in many individuals. Obesity is also associated with diabetes mellitus, stroke, and other cardiovascular diseases. Aerobic exercise 5 days a week is recommended to lower blood pressure and reduce weight. Heart-healthy advice is to quit smoking altogether, not just minimize use. Alcohol should be consumed in quantities of no more than 1 oz per day for a man and ½ oz a day for a woman.

The nurse is assessing a patient who works with chemicals and reports having a chronic cough. Which question should the nurse ask to determine a contributing factor for the cough? A. "How long have you worked around chemicals?" B. "Did you get a flu vaccine this year?" C. "Are you exposed to secondhand smoke?" D. "Where do you live?"

Answer: A Occupational exposure to chemicals is a risk factor associated with developing chronic respiratory conditions. An open-ended question regarding the patient's exposure is the best question to determine the contributing factor for the patient's cough. Flu vaccines are associated with preventing respiratory conditions, not causing them. The other questions are important secondary questions.

The reason why it is necessary to aspirate during an intramuscular injection is to: A. Avoid placement of the needle into a blood vessel. B. Produce an air pocket for better drug distribution. C. Avoid nerve puncture. D. Remove air from the syringe.

Answer: A Rationale: Aspiration of the syringe is a safety technique done while giving an IM injection to ensure that the needle is in the muscle and not in a blood vessel. Aspiration: (option 2) should not produce an air pocket, (option 3) is not used to avoid hitting a nerve, or (option 4) to remove air from the syringe.

A nurse is admitting a client to the unit who was transferred from the emergency department. Which should the nurse do to facilitate communication? A. Ensure that the client has an effective way to communicate with health-care team members. B. Use interviewing techniques to control the direction of the client's communication. C. Minimize energy spent by the client on negative feelings and concerns. D. Refocus to the positive aspects of the client's situation and prognosis.

Answer: A Rationale: A. Communication between the client and health-care providers is essential, particularly for obtaining subjective data and feedback. Speech, pantomime, writing, touch, and picture boards are examples of channels of transmission (i.e., method used to convey a message). B. The client, not the nurse, should direct the flow of communication. C. Negative feelings or concerns must be addressed. Both physical and psychic energy are used when coping with stress. D. The focus must be on the client's present concerns before refocusing to other issues because anxiety increases if immediate concerns are not addressed. Focusing on the negative sometimes is necessary before focusing on the positive.

A client is admitted to the hospital with a tentative medical diagnosis, and multiple diagnostic tests are performed. Where in the client's medical record can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reviewed by the primary health-care provider? A. Progress Notes B. Admission Sheet C. History and Physical D. Social Service Record

Answer: A Rationale: A. Generally, the Progress Notes contain documentation by all members of the health-care team. After a client is admitted and diagnostic tests are completed, the client's medical diagnosis may change. The ongoing changes and current status of the client are documented in the Progress Notes. B. The Admission Sheet is the best source for identifying the client's admitting medical diagnosis, but it will not contain the current medical diagnosis if the diagnosis changed after completion of diagnostic tests. C. The History and Physical Examination contain a history of the client, results of the physical examination, and a list of the medical problems on the day of admission to the hospital. The admission medical diagnosis may be different after diagnostic tests are completed. D. The client's medical diagnosis may or may not be documented on the client's Social Service Record; it is not the major source for this information.

A nurse places a client with a sacral pressure ulcer in the left-Sims position. How should the nurse position the client's right arm? Select all that apply. A. On a pillow B. Behind the back C. With the palm up D. In internal rotation E. With the elbow extended

Answer: A Rationale: A. In the left-Sims position, the client's right arm and leg are supported on pillows to prevent internal rotation of the shoulder and hip. B. The right arm is positioned in front of, not behind, the back. C. The right hand is positioned in pronation, not supination. D. The right arm is positioned to maintain the shoulder in functional alignment, not internal rotation. E. The right arm should be flexed slightly at the elbow; this supports comfort and functional alignment.

A nurse turns a client's ankle so that the sole of the foot moves medially toward the midline. Which word should the nurse use when documenting exactly what was done during range-of-motion exercises? A. Inversion B. Adduction C. Plantar flexion D. Internal rotation

Answer: A Rationale: A. Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the midline of the body. B. Adduction occurs when an arm or leg moves toward or beyond the midline of the body (or both). C. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg. D. Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.

Which is the earliest nursing assessment that indicates damage to tissue because of compression of soft tissue between a bony prominence and a mattress? A. Nonblanchable erythema B. Circumoral cyanosis C. Tissue necrosis D. Skin abrasion

Answer: A Rationale: A. Nonblanchable erythema refers to redness of intact skin that persists when finger pressure is applied. This is the classic sign of a stage I pressure ulcer. B. Circumoral cyanosis (slightly bluish, graying, slatelike, or dark purpose discoloration of the skin around the mouth) is an indication of hypoxia, not pressure ulcers. C. With necrosis, death of cells has occurred. Necrosis occurs in stage III and stage IV pressure ulcers. D. With an abrasion, the superficial layers of the skin are scraped away. This stage II, not stage I, pressure ulcer appears reddened and may exhibit localized serous weeping or bleeding.

A nurse turns the palm of a client's hand downward when performing range-of-motion exercises. Which word should the nurse use when documenting exactly what was done? A. Pronation B. Lateral flexion C. Circumduction D. External rotation

Answer: A Rationale: A. Pronation of the hand occurs by rotating the hand and arm so that the palm of the hand is facing down toward the floor. B. Lateral flexion of the hand occurs with both abduction (radial flexion) and adduction (ulnar flexion). With the hand supinated, radial flexion occurs by bending the wrist laterally toward the thumb, and ulnar flexion occurs by bending the wrist laterally toward the fifth finger. C. Circumduction, associated with a ball-and-socket joint, occurs when an extended extremity moves forward, up, back, and down in a full circle. D. External rotation is associated with ball-and-socket joints. External rotation of a shoulder occurs when the upper arm is held parallel to the floor, the elbow is at a 90-degree angle, the fingers are pointing toward the floor, and the person moves the arm upward so that the fingers point toward the ceiling. External rotation of the hip occurs when a leg in extension is turned so that the foot points outward from the midline of the body.

A nurse uses reflective technique when communicating with an anxious client. On which does the nurse focus when using reflective technique in this situation? A. Feelings B. Content themes C. Clarification of information D. Summarization of the topics discussed

Answer: A Rationale: A. Reflective technique requires active listening to identify the underlying emotional concerns or feelings contained in clients' messages. These feelings are then referred back to clients to promote a clearer understanding of what they have said. B. Content themes are referred back to clients through paraphrasing, which is a restatement of what was said in similar words. C. When seeking clarification, the nurse can indicate confusion, restate the message, or ask the client to elaborate in an attempt to make the client's message more clearly understood. D. Summarization is not reflective technique. Summarization reviews the significant points of the discussion to reiterate or clarify information.

A nurse places a client in the orthopneic position. Which is the primary reason for the use of this position? A. Facilitates breathing B. Supports hip extension C. Prevents pressure ulcers D. Promotes urinary elimination

Answer: A Rationale: A. Sitting in the high-Fowler position and leaning forward (orthopneic position) allow the abdominal organs to drop by gravity, which promotes contraction of the diaphragm. The arms resting on an over-bed table increase thoracic excursion. This position promotes breathing. B. The hips will be in extreme flexion, not extension. C. Pressure ulcers can still occur on the ischial tuberosities. D. Standing (for men) and sitting on a toilet/commode (for women) are superior to any position for promoting urinary elimination.

A nurse raises a client's arm forward and upward over the head during range-of-motion exercises. Which word should the nurse use when documenting exactly what was done during this range-of-motion exercise? A. Flexion B. Supination C. Opposition D. Hyperextension

Answer: A Rationale: A. The shoulder, a ball-and-socket joint, flexes by raising the arm from a position by the side of the body forward and upward to a position beside the head. B. Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. C. Opposition is the touching of the thumb of the hand to each fingertip of the same hand. D. Hyperextension of the arm occurs by moving an arm form a resting position at the side of the body to a position behind the body.

A nurse is teaching a class to nursing assistants about how to care for clients who are immobile. Which should the nurse include about why immobilized people develop contractures? A. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles. B. Muscular contractures occur because of excessive muscle flaccidity. C. Muscle mass and strength decline at a progressive rate weekly. D. Muscle catabolism exceeds muscle anabolism.

Answer: A Rationale: A. The state of balance between muscles that serve to contract in opposite directions is impaired with immobility. The fibers of the stronger muscles contract for longer periods than do those of the weaker, opposing muscles. This results in a change in the loose connective tissue to a denser connective tissue and to fibrotic changes that limit range of motion. B. Contractures occur because of muscle spasticity and shortening, not muscle flaccidity. C. Disuse and muscle wasting cause a reduction in muscle strength at the rate of 5% to 10% a week, so that within 2 months more than 50% of a muscle's strength can be lost. This results in muscle atrophy, not contractures. D. Muscle catabolism exceeding muscle anabolism is unrelated to contractures. In unused muscles, catabolism exceeds anabolism, and the muscles decrease in size (disuse atrophy).

Which interviewing skill is used when the nurse says, "You mentioned before that you are having a problem with your colostomy"? A. Focusing B. Clarifying C. Paraphrasing D. Acknowledging

Answer: A Rationale: A. This example of focusing helps the client explore a topic of importance. The nurse selects one topic for further discussion from among several topics presented by the client. B. This is not an example of clarifying, which lets the client know that a message was unclear and seeks specific information to make the message clearer. C. This is not an example of paraphrasing, which is restating the client's message in similar words. D. This is not an example of acknowledging, which is providing nonjudgmental recognition for a contribution to the conversation, a change in behavior, or an effort by the client.

A nurse is collecting data from a client for an admission nursing history. Which question by the nurse is best to open the discussion? A. "What brought you to the hospital?" B. "Would it help to discuss your feelings?" C. "Do you want to talk about your concerns?" D. "Would you like to talk about why you are here?"

Answer: A Rationale: A. This is a focused, open-ended statement that invites the client to communicate while centering on the reason for seeking health care. B. This direct question can be answered with a "yes" or "no" response. If the response is "no," then communication will be cut off. C. This direction question can be answered with a "yes" or "no" response, which may limit communication. D. This direct question can be answered with a "yes" or "no" response. The client may not like to talk, but the client may need to talk.

A client is admitted to the hospital with cirrhosis of the liver caused by long-term alcohol misuse. Which is the best response by the nurse when the client says, "I really don't believe that my drinking a couple of beers a day has anything to do with my liver problem"? A. "You find it hard to believe that beer can hurt the liver." B. "How long is it that you have been drinking several beers a day?" C. "each beer is equivalent to one shot of liquor, so it's just as damaging to the liver as hard liquor." D. "Do you believe that beer is not harmful even though research shows that it is just as bad for you as hard liquor?"

Answer: A Rationale: A. This is an example of paraphrasing. It repeats the content in the client's message in similar words to provide feedback to let the client know whether the message was understood and to prompt further communication. B. This response does not address the content or emotional theme of the client's statement. In addition, this probing question may be a barrier to further communication. C. Although factual, this response is confrontational. This nurse's statement may put the client on the defensive and inhibit further communication. D. This assertive, confronting, judgmental response may put the client on the defensive and cut off communication.

A nurse is caring for a very confused client with a diagnosis of dementia of the Alzheimer's type. Which should the nurse say when assisting the client to eat? A. "Please eat your meat." B. "It's important that you eat." C. "What would you like to eat?" D. "If you don't eat, you can't have dessert."

Answer: A Rationale: A. Very confused clients more easily understand simple words and sentences. B. This statement may not be understood by a very confused client because the word "important" involves a conceptual thought. These clients respond better to concrete communication. C. A very confused client may not be able to make a decision. D. This statement is a threat and should be avoided when talking with all clients. Also, it involves interpreting a "cause and effect" relationship.

The abbreviation "qod" was read in a patient's chart by a nursing student. The student knows that: A. This abbreviation should not be used. Instead write out "every other day". B. This abbreviation means 'every hour'. C. The abbreviation should not be used. Instead, write out "nightly". D. This abbreviation means 'four times per day'.

Answer: A Rationale: "qod" ("q"-every, "o"- other, "d"-day) is one of the abbreviations that the "Joint Commission" recommended not be used because it could cause confusion with other abbreviations. The other responses are incorrect: (option 2) every hour is written as "qh", (option 3) nightly should be written as nightly/hour of sleep, and (option 4) four times a day would be abbreviated as "qid".

The nurse checks the label three times during the course of administering a medication: while getting the medication out of the container or drawer, before placing it into the medication cup, and before administering the medication or when placing the stock bottle back on the shelf. Of the "six rights of drug administration," this nurse is checking for the: A. Right medication. B. Right documentation. C. Right patient. D. Right time of delivery.

Answer: A Rationale: In this case, the nurse is checking for information found on the label - the right medication. The right documentation (option 2), client(option 3), and time of delivery (option 4) are all parts of the "six rights of drug administration" but they are not involved in checking the medication label.

The order reads, "Lasix 40 mg IV STAT." Which of the following actions should the nurse take? A. Administer the medication within 30 minutes of the order. B. Administer the medication within 5 minutes of the order. C. Administer the medication as required by the client's condition. D. Assess the client's ability to tolerate the medication before giving.

Answer: A Rationale: STAT means immediately and the drug should be given within 30 minutes or less of receiving the order. The provider must determine the need for the medication based on the client's condition and the client's ability to tolerate the drug before writing the order. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Safe and Effective Care Environment.

When administering medications, the nurse's main responsibilities are to know and understand: (Select all that apply.) A. The medication being ordered. B. The intended use of the medication. C. Any special considerations such as the patient's age or pathophysiological state. D. Any possible side/adverse effects the medication may cause.

Answer: A Rationale: The nurse should know and understand the (option 1) medication they give, including its (option 2) intended use, (option 3) how the patient's age or disease state may affect the drug's pharmacotherapeutic response, and (option 4) any side/adverse effects it may cause.

After checking the provider's orders, the nurse notes that she is to give a medication immediately. This type of order is a(n): A. STAT order. B. single order. C. prn order. D. standing order.

Answer: A Rationale: The term "STAT" means immediately. Single (option 2), prn (option 3) and standing orders (option 4) are all types of provider's orders that the nurse may see but they do not mean that an order needs to be done immediately.

Which of the following types of drug classification focuses on what a drug does clinically? A. Therapeutic B. Pharmacologic C. Chemical

Answer: A Rationale: Therapeutic drug classification focuses on what a drug does clinically. Pharmacologic drug classification (option 1) focuses on a drug's mechanism of action, the term "chemical" in term of pharmacology focuses on the actual composition of a drug (option 3), therefore option 4 is incorrect because there was only 1 correct answer.

Injections should begin with a A. Quick, dart like piercing of the skin B. Slow piercing of the skin (piercing slowly, counting to 10)

Answer: A Rationale: Yikes, would you like a needle to go in slowly? That would hurt. A quick dart like action will help with the pain perception.

The nurse is caring for a patient with a history of respiratory issues. Which lifestyle factor is the priority to address? A. Smoking history B. Weight C. Gender identity D. Age

Answer: A Smoking leads to many respiratory and cardiovascular pathologies and exacerbates all others. Patients who smoke should be offered counseling and assistance with cessation. Gender identity has no influence on respiratory status. Age and weight may affect the patient's respiratory status, but they are not priorities.

Which oxygen delivery device should the nurse understand is indicated for a patient with a CO2 level of 55 mmHg? A. Nonrebreather mask B. Simple face mask C. Oxymizer D. Nasal cannula

Answer: A The nonrebreather mask has a one-way valve between the attached reservoir and the face mask that ensures the appropriate levels of oxygen are inhaled, with no CO2 from exhaled gases. CO2 rebreathing by the patient is not prevented by a simple face mask, a nasal cannula, or an Oxymizer.

During a home visit, the nurse evaluates the self-care ability of a patient recovering from deep vein thrombosis (DVT). Which observation indicates that additional teaching is required to the patient? A. The patient has removed the compression stockings. B. The patient is sitting with the legs elevated. C. The patient frequently changes position. D. The patient is taking warfarin as prescribed.

Answer: A The patient should be wearing compression stockings as prescribed; this observation indicates that additional teaching is required. Taking warfarin as prescribed, elevating the legs, and frequent position changes indicate that teaching has been effective.

Where should the nurse feel the strongest vibration when performing tactile fremitus on a patient? A. Over the trachea B. Over the alveoli C. Over the lower half sternum D. Over the bronchioles

Answer: A The strongest vibration should be felt over the trachea. Harsh, high-pitched sounds are normal sounds heard over the trachea when the patient inhales and exhales. They will diminish over the bronchi and become almost nonexistent over the alveoli of the lungs. The lower half of the sternum is too low.

The nurse is caring for a patient with a pleural effusion. Which test should the nurse expect to be ordered? A. Thoracentesis B. Bronchoscopy C. Arterial blood gases (ABGs) D. Pulmonary function test (PFT)

Answer: A Thoracentesis is used to remove fluid from the pleural space. Bronchoscopy is an invasive procedure and would not be used for fluid in the pleural space. PFT is used to measure changes in lung function but is not used to treat pleural effusions. ABG test for acid-base imbalance but are not a treatment for pleural effusions.

The nurse is caring for a patient with a pneumothorax. Which factor should the nurse suspect caused this alteration? A. Trauma B. Obesity C. Pneumonia D. Asthma

Answer: A While a pneumothorax may occur spontaneously, most occur as the result of trauma. Obesity can cause apnea. Asthma and pneumonia can cause orthopnea.

8) A nurse working in the Neonatal Intensive Care Unit (NICU) is caring for a preterm infant with a congenital heart defect. The nurse knows that these conditions are categorized by: A) Severity of defect. B) Pathophysiology and hemodynamics of defect. C) Location of defect. D) Age when defect diagnosed.

Answer: B

A 62-year-old female client has been diagnosed with narrowing of the coronary arteries. What would be the appropriate, conservative initial treatment for this condition? A. Exercise for 30 minutes 3 times a week. B. Cut smoking by half the usual amount. C. Eat a diet with a minimum of 20% fat. D. Take statin medications as prescribed.

Answer: A Rationale: Conservative treatment would include regular physical exercise such as walking at a brisk pace. Fat should be no more than 10% of the daily diet. Smoking should be totally eliminated, usually through a cessation program or the use of assistive drugs such as nicotine patches. By controlling cholesterol, the client can help control coronary artery disease (CAD). The statins are one group of medications used to decrease circulating cholesterol. Prescribing a statin would be a more aggressive treatment.

An client who is obese and who has a history of heart disease and heart failure (HF) is in an intensive care unit. The client is having a very difficult time getting comfortable in bed. The client has difficulty sleeping and becomes short of breath upon lying down in bed. Which nursing intervention could help promote comfort? A. Elevating the head of the bed and providing extra pillows B. Obtaining an order for a sleeping pill C. Increasing the client's oxygen at night D. Advising family to stay with the client at night

Answer: A Rationale: Elevating the head of the bed can help those with heart failure or poor perfusion breathe more comfortably. Increasing oxygen may provide some short-term relief, but it will not help with client comfort in the long term. The nurse should assist the client into a position of comfort, with extra pillows and the head of the bed elevated, and promote a restful environment in the room. Clients with poor perfusion are often unable to lie flat due to decreased pulmonary perfusion, which provides oxygen to the bloodstream. In clients with HF, the nurse should anticipate assisting with positions of comfort.

Which is an effective nonpharmacologic therapy for impaired perfusion in the lower extremities? A. Compression stockings B. Ventricular assist device C. Sitting with both feet on the floor D. Orthopedic shoes

Answer: A Rationale: Impaired perfusion in the lower extremities is often treated with compression stockings. Compression stockings are worn to prevent pooling of blood in the veins of the lower extremities. Blood can pool when venous blood return is not efficient. The collected blood can form clots that can dislodge and travel to the lungs, resulting in pulmonary embolism, or to the brain, resulting in stroke.

A 65-year-old client presents to the emergency department with a 3-day history of diarrhea and vomiting. The nurse notices that the client's pulse is 128 bpm. What is the most likely cause of the increased heart rate? A. Dehydration from loss of fluids B. Stress from being sick C. The client's age D. Effects of medications the client has taken

Answer: A Rationale: Pulse rate will increase in response to hypovolemia to maintain an adequate cardiac output. Factors such as stress, age, medications, exercise, and lifestyle can alter a person's pulse. In this scenario, the client had a history of diarrhea and vomiting and likely was experiencing hypovolemia. The nurse should expect to begin IV fluid hydration.

Which is most likely to be a normal assessment finding in an 80-year-old client? A. Resting heart rate of 62 beats/min B. Heart rate of 110 beats/min C. Blood pressure of 160/90 mmHg D. Irregular heart rhythm

Answer: A Rationale: Resting heart rate is relatively unchanged with normal aging. Blood pressure of 160/90 mm/Hg is elevated and not normal for an adult. While BP elevation frequently occurs with aging, it is not considered a normal variant. A heart rate over 110 beats/min is not considered normal for an older adult. An irregular heart rhythm is an expected finding that may be controlled, but it is not a normal assessment finding.

The nurse assessing a newborn suspects respiratory distress. Which finding supports the suspicion? A. Intercostal retractions B. Respiratory rate of 44 C. Acrocyanosis at birth D. Abdominal breathing

Answer: A Rationale: Retraction of the intercostals occurs with respiratory distress. A respiratory rate of 44, abdominal breathing, and acrocyanosis are normal findings for neonates/newborns.

A 70-year-old client is ambulating to the bathroom with assistance. The client becomes very short of breath and anxious on the way. The client begins to cry and ask for help. What is the most appropriate initial nursing intervention? A. Call for assistance, bring a chair, and assist the client to a sitting position. B. Encourage the client to continue walking to the bathroom. C. Ask if the client would rather use a bedpan. D. Quickly assist the client back to bed.

Answer: A Rationale: The nurse should provide reassurance and reduce anxiety. Assisting the client into a sitting position quickly and relieving anxiety is the safest and most appropriate nursing action. Assisting the client back to bed may prolong the anxiety due to needing to go to the bathroom. Encouraging the client to continue walking may increase stress. Asking if the client prefers a bedpan is appropriate but not the most immediate need.

A client who has been diagnosed with new onset atrial fibrillation has been prescribed warfarin, an anticoagulant. Which statement of instruction should the nurse provide? A. "You should shave with an electric razor." B. "Take an additional warfarin if you heart rate increases." C. "It is recommended that you avoid eating foods high in protein." D. "Do not take warfarin if your pulse is below 65."

Answer: A Rationale: Warfarin is an anticoagulant used to prevent the formation of clots in clients with atrial fibrillation. Clients who take warfarin should be on bleeding precautions, because the ability of their blood to form clots is compromised. Clients should be instructed to shave with an electric razor and avoid working with sharp objects. Clients should notify the technician prior to having blood drawn.

A patient has been taking a statin medication for about 4 weeks when they are seen for a follow-up appointment. The patient mentions that when they drink wine with dinner, they tend to feel "funny." How should the nurse respond to the patient? A. "Alcohol tends to make me feel funny too! Maybe you could switch to a different kind or just drink a bit less if you feel that it is affecting you." B. "You should stop drinking alcohol altogether while taking this medicine; this was something we should have discussed when you went home with the prescription." C. "Some patients experience a short period that feels funny after starting the medicine wherein their body must get used to it. I'm sure that you will eventually not feel funny at all if you have a glass of wine." D. "If you know that you will be drinking at a certain time of the day, you can take the medication at a different time. For instance, if you know you will have wine with dinner, you should take the medicine in the morning when you wake up."

Answer: B

A primary health-care provider prescribes nose drops to be administered twice a day. Which should the nurse do when instilling the nose drops? Select all that apply. A. Tell the client not to sniff the medication once administered B. Place the client in the supine position with the head tilted backward C. Pinch the nares of the nose together briefly after the drops are instilled D. Instruct the client to blow the nose 5 minutes after the drops are instilled E. Insert the drop applicator 1/2 inch into the nose toward the base of the nasal cavity

Answer: A, B A. Avoiding sniffing the nose drops after administration allows the medication to reach desired areas (ethmoid and sphenoid sinuses) via gravity. B. This position ensures that gravity will promote the flow of medication to the nasopharynx. Five minutes is the length of time the client should remain in the supine position with the head tilted backward. C. Pinching the nose is unnecessary and can frighten the client, who already may be having difficulty breathing. D. Blowing the nose should be avoided because it may remove medication from the nose. E. Nose drops should be directed toward the midline of the ethmoid bone, with the dropper held 0.5 inches above the nares. Holding the dropper 0.5 inches above the nares prevents contamination of the dropper.

Which ability of the nurse is important to achieve effective therapeutic communication? Select all that apply. A. Using interviewing skills B. Remaining nonjudgmental C. Sending only verbal messages D. Being assertive when collecting data E. Displaying sympathy when communicating

Answer: A, B Rationale: A. Communication is facilitated by interviewing techniques that elicit client attitudes, behaviors, and verbal messages. Interviewing skills promote therapeutic communication because they are client centered and goal directed. B. A nonjudgmental attitude communicates acceptance to the client, which provides emotional support and precipitates further communication. C. Communication involves both verbal and nonverbal messages. Often, nonverbal messages carry more meaning than verbal messages because actions speak louder than words. D. Assertiveness when collecting data may be perceived by the client as aggression, which is a barrier to communication. E. A therapeutic relationship should avoid sympathy because it implies pity. The nurse should empathize, not sympathize, with clients.

Which action employed by the nurse indicates acceptable body mechanics to avoid self-injury? Select all that apply. A. Keep back, neck, pelvis, and feet aligned. B. Position oneself close to the client. C. Keep knees and hips slightly flexed. D. Arrange for adequate help. E. Keep feet close together.

Answer: A, B, C, D Rationale: A. Alignment reduces the risk of lumbar vertebrae and muscle group injury resulting from torquing (twisting). B. Positioning oneself close to the client keeps the client closer to your center of gravity. Increased stability reduces strain on back muscles. C. Keeping knees and hips slightly flexed facilitates using the large muscles of the legs, rather than the back, to move the client. D. Multiple caregivers share the load of moving a client safely. E. Feet should be positioned wide apart, not close together, to provide a wide base of support, which increases stability.

A nurse is caring for a client receiving oxygen via a nasal cannula. Which of the following should the nurse implement? Select all that apply. A. Apply a water-based lubricant to the client's nares. B. Adjust the flowmeter to the prescribed oxygen flow rate. C. Reassess nares, cheeks, and ears for signs of pressure every 2 hours. D. Place the nasal prongs so that they curve downward when in the nares. E. Loop the tubing over the client's ears and adjust it gently under the chin.

Answer: A, B, C, D, E A. A water-based lubricant will keep the nares supple. An oil-based lubricant should not be used because volatile, flammable substances can ignite in the presence of oxygen. B. Adjusting the flowmeter to the prescribed oxygen flow rate ensures that the client is receiving the accurate dose of oxygen. C. Reassessing the client's skin for signs of pressure every 2 hours ensures that tissue irritation or capillary compression does not occur from the nasal prongs or tubing. The tubing should be snug enough to keep the nasal prongs from becoming displaced but loose enough not to compress or irritate tissue. D. Placing the nasal prongs curving downward in the nares follows the natural curve of the nasal passages, preventing injury. E. Looping the tubing over the client's ears and adjusting it gently under the chin is the correct placement of the tubing. A firm adjustment can cause pressure ulcers around the ears.

Which nursing action should the nurse implement when speaking with an older adult whose hearing is impaired? Select all that apply. A. Limit background noise. B. Enunciate words without exaggeration. C. Use gestures to augment communication. D. Stand directly in front of the client when speaking. E. Talk in a normal rate and volume when speaking with the client.

Answer: A, B, C, D, E Rationale: A. Limiting competing stimuli promotes reception of verbal messages. B. Clear enunciation permits lip reading by the client. Overexaggeration of lip movements may be demeaning and interfere with lip reading. C. Use of gestures and facial expressions supplements verbal messages. D. Standing directly in front of the client when speaking helps to focus the client's attention on the nurse. A hearing-impaired individual must be aware that a message is being sent before the message can be received and decoded. E. Talking in a normal rate and volume promotes communication. Raising the volume of the voice is demeaning and may be viewed by the client as aggressive behavior.

A nurse is planning to help move a client up in bed. Which of the following can the nurse implement to reduce the risk of self-strain when performing this action? Select all that apply. A. Use the force of gravity to facilitate the move. B. Keep the upper and lower body in alignment. C. Use the large muscles of the legs. D. Keep the knees slightly bent. E. Raise the bed to waist level.

Answer: A, B, C, D, E Rationale: A. Muscle strain is reduced when clients are moved by using gravity, not with the added effort needed to move clients against gravity. B. Keeping the upper and lower body in alignment decreases strain on the sacrospinal muscles and intervertebral disks. C. To exert an upward lift, the gluteal and leg muscles should be used, rather than the sacrospinal muscles of the back. The gluteal and leg muscles are larger than the sacrospinal muscles and therefore fatigue less quickly, and their use protects the intervertebral disks. D. The muscles of the legs are most efficient when the knees and hips are slightly bent. This reduces strain on the muscles being used. E. Positioning the bed at waist height avoids the need to reach and stretch, which may strain a caregiver's muscles, bones, joints, tendons, or ligaments.

5) The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease. What should be included in this teaching? Select all that apply. A) Limit exercise to 15 minutes a day. B) Reduce saturated fats in the diet. C) Avoid cigarette smoking. D) Wear elastic hose. E) Limit fluid intake.

Answer: B, C

The nurse is participating in a community health clinic. Which client should the nurse identify as being at risk for compromised oxygenation? (Select all that apply.) A. A 64-year-old woman with osteoporosis and limited mobility B. A 56-year-old man who has been working at a textile factory C. A 46-year-old woman with a history of anxiety attacks D. A 70-year-old woman who eats a well-balanced diet and exercises daily E. A 28-year-old man who smokes with a 10 pack per year history

Answer: A, B, C, E Rationale: Clients with occupations that cause them to inhale chemicals and dust are at increased risk for developing lung disease. Individuals who live a sedentary lifestyle have diminished alveolar expansion, placing them at risk for altered respiratory function. Additionally, musculoskeletal impairment such as kyphosis (which may result from osteoporosis) diminishes lung capacity. Clients who smoke are at risk for pulmonary and cardiac disease. High levels of anxiety can cause bronchospasms and the onset of bronchial asthma. Some clients hyperventilate in response to stress. The client's arterial oxygen levels rise, and the arterial carbon dioxide levels decline. Intake of a diet high in fat predisposes clients to cardiovascular disease.

1) An older client is diagnosed with dilated cardiomyopathy. What will the nurse most likely assess in this client? Select all that apply. A) Fatigue B) Lower extremity edema C) Syncope D) Dyspnea E) Jugular vein distention

Answer: A, B, D, E

7) The nurse is assessing a toddler diagnosed with tetralogy of Fallot. Which assessment findings should the nurse determine as being consistent with this child's diagnosis? Select all that apply. A) Palpable thrill in the pulmonic area B) Nail clubbing C) Cough D) Apneic periods E) Knee e-chest position

Answer: A, B, E

A nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the group understands how to implement medication therapy? (Select all that apply.) A. "I will observe for side effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occurs." E. "I will refuse to give a medication if I believe it is unsafe."

Answer: A, B, E A. Correct: The nurse is responsible for observing for side effects. This is within a nurse's scope of practice. B. Correct: The nurse is responsible for monitoring therapeutic effects. This is within a nurse's scope of practice. C. The provider is responsible for prescribing the appropriate dose. This is outside of the nurse's scope of practice. D. The provider is responsible for changing the dose if adverse effects occur. This is outside of the nurse's scope of practice. E. Correct: The nurse is responsible for identifying when a medication could harm a client. It is within the nurse's scope of practice to refuse to administer the medication and contact the provider.

The nurse is assessing an 8-year-old client. Which anatomical difference should the nurse expect to find compared to an adult? (Select all that apply.) A. Small mouth with large tongue B. Soft tracheal cartilage C. Larynx and glottis lower in the neck D. Atrophy of the tonsils E. Smaller nasopharynx

Answer: A, B, E Rationale: Normal findings for the pediatric client from infancy until the age of 12 include a smaller nasopharynx, a small mouth with a large tongue, and soft tracheal cartilage. The nurse would expect to find enlarged tonsils; atrophy does not occur until after 12 years of age. The nurse would expect the larynx and the glottis to be higher in the neck, not lower.

Which routes are unrelated to the parenteral administration of medications? Select all that apply. A. Buccal B. Z-track C. Sublingual D. Intravenous E. Intradermal

Answer: A, C A. A parenteral route is outside the gastrointestinal tract. A medication administered by the buccal route dissolves between the cheeks and gums, where it acts on the oral mucous membranes or is swallowed with saliva. Most troches are used for their local effect. B. Z-track is a method of administered an intramuscular injection. The intramuscular route is a parenteral route. C. A parenteral route is outside the gastrointestinal tract. With the sublingual route, medication dissolves under the tongue, where it is rapidly absorbed. D. The IV route, a parenteral route, instills medication directly into the venous circulation. E. The intradermal route, a parenteral route, injects medication just under the epidermis.

A primary health-care provider prescribes a rectal suppository for an adult client. Which action should the nurse implement when administering the rectal suppository? Select all that apply. A. Lubricate the medication before insertion B. Warm the medication equal to body temperature C. Instruct the client to take deep breaths through the mouth D. Insert the medication just inside the rectum's external sphincter E. Place the client in the prone position to administer the medication

Answer: A, C A. Lubrication eases insertion by reducing friction, which limits tissue trauma and discomfort. B. Warming the medication causes it to melt, making it impossible to insert. Most rectal suppositories are kept refrigerated until used. C. Taking deep breaths relaxes the rectal sphincters. D. Rectal suppositories should be inserted 3 inches into the rectal canal past the rectum's internal sphincter of an adult. This can be accomplished by using the full length of a lubricated, gloved index finger to place the suppository. E. The client should be place in the left-lateral or left-Sims position to take advantage of the anatomical curve of the rectum and sigmoid colon.

A nurse is to administer an eye irrigation to a client's right eye. Which should the nurse do? Select all that apply. A. Direct the flow of solution from the inner to the outer canthus. B. Irrigate with a bulb syringe held several inches above the eye. C. Expose the conjunctival sac and hold open the upper lid. D. Don sterile gloves before beginning the procedure. E. Position the client in a right lateral position.

Answer: A, C A. This action prevents secretions and fluid from entering and irritating the lacrimal ducts. B. A bulb syringe produces a flow of fluid that is forceful and difficult to control. An IV bag of solution is preferred to provide a flow of fluid by gravity that is gentle and controllable. C. These actions provide access to the eye. D. Medical, not surgical, asepsis is required for this procedure. E. The client should be placed in a sitting or back-lying position with the head tilted toward the affected eye.

2) A client tells the nurse that he knows he has high blood pressure but does not want to take any medication. Which health problem is the client at risk of developing? A) Gastritis B) Diabetes C) Cardiomyopathy D) Metabolic syndrome

Answer: C

A primary health-care provider prescribes a standard walker for a client who has left-sided weakness and requires some assistance with balance but can bear weight on both legs. Which should the nurse teach the client about how to use the walker safely? Select all that apply. A. Advance the strong leg last by itself. B. Lift the walker before moving it forward twelve inches. C. Advance the walker and the weak leg ahead together first. D. Adjust the height of the walker so that it is equal with the hip joint. E. Roll the walker a comfortable distance ahead before stepping forward.

Answer: A, C Rationale: A. Advancing the unaffected leg last by itself allows weight to be borne by the affected leg while both arms are supported on the walker. B. Six, not 12, inches is the proper distance to advance a walker. Twelve inches will require the client to reach too far forward, moving beyond a stable center of gravity. C. Advancing the walker and the affected leg together ensures that weight is borne by the unaffected leg. D. Adjusting the height of the walker so that it is equal with the hip joint is too low and will require the client to stoop to each the hand bar. The hand bar should be at a height just below the client's waist, allowing the elbows to be slightly flexed. A walker that is the correct height allows a client to assume a more functional posture. E. A standard walker does not have wheels. Directing a person to advance a walker a comfortable distance is unsafe. The word "comfortable" is subjective and unclear. Walkers should be advanced 6 inches at a time to ensure that a person's weight does not extend beyond the center of gravity.

What is the role of the nurse in medication administration? (Select all that apply.) A. Ensure that medications are administered and delivered in a safe manner. B. Inform the client that prescribed medications need to be taken only if the client agrees with the treatment plan. C. Ensure that the client understands the use and administration technique for all prescribed medications. D. Prevent adverse drug reactions by properly administering all medications.

Answer: A, C Rationale: Ensuring client safety when administering prescribed medications by following all medication administration procedures and providing client education about the use and administration of the prescribed medications are the nurse's responsibility. Options 2, and 4 are incorrect. Clients have the right to refuse medications, but the nurse should verify the plan of care and the reasons for the medications with the client before administration. Adverse drug reactions may occur regardless of the proper administration technique. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Health Promotion and Maintenance.

A primary health-care provider prescribes two oral medications for a client with a nasogastric tube on low continuous suction. Which action should the nurse implement when administering this mediation? Select all that apply. A. Give each medication separately B. Follow medication administration with 100 mL of free water C. Crush crushable tablets into a fine powder and mix with 30 mL of warm water D. Shut off nasogastric tube suctioning for 30 minutes after medication administration E. Ensure nasogastric tube placement by instilling 30 mL of air while auscultating over the epigastric area for a "whooshing" sound

Answer: A, C, D A. If the tube used to administer a medication via a nasogastric tube becomes accidentally disconnected during administration, the nurse can identify the approximate volume of the one medication that was lost when reporting the event to the primary health-care provider. B. Oral medication via a nasogastric tube should be followed by 30 mL, not 100 mL, of tap water to ensure tube patency. Free water refers to larger volumes of water administered at routine intervals as per a prescription by a primary health-care provider. C. Crushing crushable tablets into a fine powder and mixing the powder with 30 mL of warm water dissolves the medication and prevents clogging the enteral tube. D. Shutting off nasogastric tube suctioning for 30 minutes after medication administration enhances medication absorption in the stomach. E. This method is the most unreliable method of assessing placement of a nasogastric tube. Measuring the pH of gastric aspirate is more accurate. A low pH (1 to 5; acidic) indicates the tube probably is in the stomach; a high pH (more than 6; alkaline) indicates the tube probably is in the intestine or the respiratory tract.

A primary health-care provider prescribes an oral medication for a client. The nurse identifies that the client is having some difficulty swallowing. What should the nurse plan to do? Select all that apply. A. Crush tablets that are crushable and mix with a small amount of applesauce B. Have the client hyperextend the neck slightly when swallowing C. Give water before, during, and after medication administration D. Stroke under the chin over the larynx E. Have the client use a straw

Answer: A, C, D A. Reducing the size of a tablet and mixing it with a food the consistency of applesauce facilitate ingestion and minimize the risk of aspiration. The thickness of applesauce is easier to control in the mouth than water for a person who has difficulty swallowing. B. Hyperextending the neck when swallowing facilitates entry of the substance ingested into the trachea; this action is unsafe. Slightly flexing, not hyperextending, the neck helps to open the esophagus and bypass the trachea when swallowing. C. Giving a small amount of fluid before, during, and after medication administration lubricates the oral cavity and facilitates movement of medication toward the esophagus and stomach. D. Stroking under the chin over the larynx encourages laryngeal elevation, which facilitates swallowing. E. A straw deposits fluid in the back of the mouth and does not allow time for a coordinated approach to swallowing. The use of a straw increases the risk of aspiration.

A client is to have arthroscopic surgery of the knee to repair a torn tendon. The client says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the client? Select all that apply. A. "The type of surgery you are having is minor." B. "Surgery often can be frightening." C. "Everything will be all right." D. "You are not going to die." E. "You sound scared."

Answer: A, C, D Rationale: A. This response minimizes the client's concerns. It is major, not minor, surgery for this client. B. This example of reflective technique focuses on feelings, which promotes communication. C. This response is false reassurance. It denies the client's concerns about survival and does not invite the client to elaborate. D. This response denies the client's feelings and is false reassurance. Also, it closes communication and does not provide the client with an opportunity to discuss concerns. E. This example of reflective technique identifies feelings, which promotes communication.

2) The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client? A) Risk for Infection related to engorged pulmonary vasculature B) Interrupted Family Processes C) Decreased Cardiac Output D) Excess Fluid Volume

Answer: C

A nurse is interviewing a newly admitted client in the process of completing a nursing admission history and physical assessment. Which information should be included in a medication reconciliation form? Select all that apply. A. Vitamins B. Drug allergies C. Food supplements D. Over-the-counter herbs E. Prescribed medications

Answer: A, C, D, E A. Vitamins are a medication and should be included on a medication reconciliation form. An accurate list of all the drugs that a client is taking (e.g., name, dose, route, and frequency) should be reconciled on admission and during transitions (e.g., transfer between units, shift reports, when new medication administration records are implemented, and at discharge). This list should be compared with new medications prescribed and education provided to the client about each medication. B. Generally, drug allergies are documented on a health history, not on the drug reconciliation form. C. Food supplements are considered medications because they often contain ingredients that may interact with medicinal products. D. Over-the-counter herbs are considered medications because they contain ingredients that may unfavorably interact with medicinal products. E. Prescribed medications should be included on a medication reconciliation form.

The nurse is planning care for a client with weight loss related to respiratory alterations. Which intervention should the nurse include? (Select all that apply.) A. Select foods to meet caloric requirements. B. Encourage the client to eat three full meals every day. C. Consult with a dietitian. D. Supply nutritional supplements during the day. E. Choose foods the client enjoys.

Answer: A, C, D, E Rationale: Individuals with respiratory alterations often need an increased calorie intake but lack the endurance to consume adequate nutrition. Increased calories are necessary because the client is burning more calories due to the increased work of breathing. A nutritionist is able to assist the individual to select foods and supplements the client enjoys to meet daily caloric and nutritional needs. A nutritionist can guide the individual in developing menus consisting of frequent, small, nutritious meals.

A nurse is caring for a client who has a chest tube after thoracic surgery. Which of the following should the nurse implement when caring for this client? Select all that apply. A. Encourage the client to cough and deep breathe at regular intervals. B. Clamp the tube when providing for activities of daily. C. Position the collection device below the level of the chest. D. Maintain an airtight dressing over the puncture wound. E. Empty drainage from the device every shift. F. Avoid using pins to secure tubing.

Answer: A, C, D, F A. Coughing and deep breathing should be encouraged because this helps to expand the lungs. B. Clamping the tube when providing for activities of daily living is contraindicated because clamping a chest tube may cause a tension pneumothorax. C. The chest drainage system should be kept below the level of the insertion site to promote the flow of drainage from the pleural space and prevent the flow of drainage back into the pleural space. D. An airtight dressing seals the pleural space from the environment. If the pleural space is left open to the environment, atmospheric pressure causes air to enter the pleural space, which results in a tension pneumothorax. E. Emptying chest tube drainage every shift is unnecessary. Chest drainage systems are closed, self-contained systems that have a chamber for drainage. At routine intervals (as per hospital policy), the date, time, and nurse's initials mark the level of drainage on the drainage collection chamber. F. Avoiding using pins to secure tubing averts the risk of puncturing the tubing, which will cause an air leak.

A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medications? (Select all that apply). A. 0905 B. 0825 C. 1000 D. 0840 E. 0935

Answer: A, D A. Correct: The nurse should administer medications within 30 min of the time it is due. 0905 is within 30 min of the time the medication is due. B. 0825 is not within 30 min of the time the medication is due. C. 1000 is not within 30 min of the time the medication is due. D. Correct: 0840 is within 30 min of the time the medication is due. E. 0935 is not within 30 min of the time the medication is due.

A nurse concludes that a client has the potential for impaired mobility. Which of the following reflect risk factors that support this conclusion? Select all that apply. A. Joint pain B. Exertional fatigue C. Sedentary lifestyle D. Limited range of motion E. Increased respiratory rate

Answer: A, D Rationale: A. Joint pain may prevent the client from moving about, leading to contractures that result in impaired mobility. B. Exertional fatigue is associated with activity intolerance. People who are fatigued are still able to move. C. People who are sedentary are still able to move. D. Limited range of motion is associated with contracture formation and impaired mobility. E. An increased respiratory rate is a response to activity, not impaired mobility.

Which should the nurse never do when documenting information on a client's electronic medical record? Select all that apply. A. Leave the client's medical record open on the computer screen when entering the client's room to administer a medication. B. Share information verbally about a client with another nurse who is also caring for the client. C. Document nursing care administered to a client immediately after it is completed. D. Give a personal access code to another member of the health-care team. E. Document exact quotes of a client's subjective information.

Answer: A, D Rationale: A. Leaving the client's medical record open on the computer screen violates client confidentiality as well as leaves the file vulnerable to another person contaminating the information in the file. B. A nurse should communicate, verbally and in writing, important information to other members of the health-care team responsible for caring for the client. Valuable time may lapse before other members of the team read the client's electronic medical record. C. Documenting care immediately after it is administered ensures that the information is in the client's medical record. Also, delaying documentation may result in the nurse's forgetting to include pertinent information. D. A nurse should never share a personal access code. This ensures that only the nurse assigned the code can insert information into the electronic medical record via that code. This protects the nurse who has the code. E. Inclusion of exact client statements prevents the nurse from including personal interpretations that may not be accurate.

4) A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating, and fatigued with routine care activities. The nurse would identify which of the following nursing diagnoses as being appropriate for this client? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Knowledge C) Activity Intolerance D) Self-Care Deficit

Answer: C

A risk manager is conducting a retrospective audit of a client's clinical record to identify the use of unacceptable abbreviations. Which abbreviation did the risk manager identify that is on The Joint Commission official Do Not Use List? Select all that apply. CLIENT'S CLINICAL RECORD Medication Administration Record - MS 4 mg subcutaneous at 1400 hour and client expressed relief within 15 minutes. - Client's serum glucose was 180 at 1700 hour; 4 U regular insulin administered subcutaneously as prescribed. Intake and Output Record - 0800 hour: Milk 60 ml, orange juice 120 ml; coffee 120 ml Progress Note - Client to be discharged in a.m. and will receive physical therapy QOD. A. U B. ml C. mg D. MS E. QOD F. 0800 hour

Answer: A, D, E Rationale: A. The abbreviations U and u for units are on The Joint Commission's official Do Not Use List. These abbreviations may be mistaken for the number 0, the number 4, or cc. The word unit should be written out in full. B. An abbreviation for milliliter is ml. The abbreviation ml is not on The Joint Commission's official Do not Use List. C. The use of the abbreviation mg for milligram is not on The Joint Commission's official Do Not Use List. D. The abbreviation MS for morphine sulfate is on The Joint Commission's official Do Not Use List. MS can be mistaken for morphine sulfate or magnesium sulfate. The name of the medication should be spelled out in full. E. The use of the abbreviation QOD for every other day is on The Joint Commission's official Do Not Use List. Other abbreviations for every other day include qod, q.o.d., and Q.O.D., and they also are on The Joint Commission's official Do Not Use List. "Every other day" should be written out in full. F. The use of 0800 represents 8 a.m. in military time. This reflects acceptable documentation.

12) A nurse is educating a client with cardiomyopathy about diet choices which are appropriate for the client's condition. The nurse will include all statements except: A) "It is important to monitor your sodium intake." B) "Increasing your dietary protein helps with cardiac cell repair." C) "Here is a list of high-fat, high-cholesterol foods to avoid." D) "I have notified the dietitian regarding your condition in order to provide you with more information."

Answer: B

2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Cluster activities. B) Instruct on deep breathing. C) Medications appropriate to increase heart rate D) Positioning to increase blood return

Answer: B

3) An older client diagnosed with cardiomyopathy reports having to rest between activities during the day. What should the nurse realize is the reason for this client's fatigue? A) Increased stroke volume B) Decreased cardiac output C) An elongated and dilated aorta D) Increased blood pressure

Answer: B

4) The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching provided to these parents has been effective? A) "Our child should be restricted in play and activity for at least 6 months." B) "Our child will need to take antibiotics prior to having dental surgery." C) "Fluids should be restricted to maximize lung function." D) "Our child should not return to normal activities for at least 2 years."

Answer: B

6) A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery? A) Restricting immunizations until after the surgery B) Preventing exposure to infection C) Implementing no particular precautions D) Restricting fluids

Answer: B

6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not sleeping well. What should the nurse suspect this client is experiencing? A) Pancreatic disease B) Cardiac disease C) Normal changes of aging D) Signs of anemia

Answer: B

A nurse is caring for a male client who had several laboratory tests performed. Which of the following increase the client's risk for an impaired ability to tolerate activity? Select all that apply. A. Hct of 45% B. Hb of 10 g/dL C. O2 saturation of 97% D. WBC count of 7,500 cells/mcL E. RBC count of 4.8 million cells/mcL

Answer: B A. A hematocrit of 45% is within the expected range for hematocrit for men (42% to 52%). The expected hematocrit range for women is 36% to 48%. B. A hemoglobin of 10 g/dL is less than the expected range for hemoglobin for men (14.0 to 17.4 g/dL). the expected hemoglobin range for women is 12.0 to 16.0 g/dL. C. Adequate oxygen levels of more than 95% are necessary to meet the metabolic demands of activity that requires muscle contraction. D. A white blood cells (WBC) count of 7,500 cells/mcL is within the expected range of 3,500 to 10,500 cells/mcL for WBCs. WBCs are not related to a client's oxygenation status; they are related to protecting the client from infection. E. A red blood cell count of 4.8 million cells/mcL is within the expected range of 4.2 to 5.4 million cells/mcL for red blood cells for men.

Which action should be implemented by the nurse when a medication is delivered by the Z-track method? A. Use a special syringe designed for Z-track injections B. Pull the skin laterally away from the injection site before inserting the needle C. Administer the injection in the muscle on the anterolateral aspect of the thigh D. Insert the needle in a separate spot for each dose on a Z-shaped grid on the abdomen

Answer: B A. A special syringe is not needed for administering a medication via Z-track. The barrel of the syringe must be large enough to accommodate the volume of solution to be injected (usually 1 to 3 mL) and the needle long enough to enter a muscle (usually 1.5 inches). B. This action creates a zigzag track through the various tissue layers. The track prevents backflow of medication up the needle track when simultaneously removing the needle and releasing the traction on the skin after the medication is injected. C. The use of the vastus lateralis muscle for a Z-track injection may cause discomfort for the client. Z-track injections are tolerated more when the well-developed gluteal muscles are used. D. The needle is inserted into the muscle once for a Z-track injection. The Z represents the zigzag pattern of the needle track that results when the skin traction and the needle are simultaneously removed.

Which should the nurse use when administering a subcutaneous injection? A. 5-mL syringe B. 25-gauge needle C. Tuberculin syringe D. 1.5-inch-long needle

Answer: B A. A subcutaneous injection should not exceed 1 mL. A 3-mL, not a 5-mL, syringe is acceptable for a subcutaneous injection. B. A subcutaneous injection should use a 25- to 29-gauge needle, which minimizes tissue trauma. The diameter of a needle is referred to as its gauge, which ranges from 28 (small) to 14 (large). C. The volume of a tuberculin syringe is only 1 mL. For most subcutaneous injections, a syringe that can accommodate up to 3 mL is preferred to facilitate handling of the syringe. D. A 1.5-inch length is appropriate for an intramuscular, not a subcutaneous, injection.

Which should the nurse do first when an adult who is choking on food become unconscious? A. Apply upward thrusts over the client's xiphoid process. B. Initiate a cardiopulmonary resuscitation protocol. C. Strike the middle of the client's back firmly. D. Perform a blind finger sweep of the mouth.

Answer: B A. Abdominal thrusts should not be performed on people who are unconscious because of a foreign body airway obstruction. Another intervention is more effective. B. Chest compressions are more effective than abdominal thrusts when attempting to eject a foreign body obstructing the airway of an unconscious adult. Chest compressions more effectively raise intrathoracic pressure. C. Hitting the middle of the client's back firmly should never be done for an unconscious adult who is choking. The American Red Cross advocates alternating 5 back blows and 5 abdominal thrusts for a conscious adult who is choking. D. A blind finger sweep should never be performed because it may push the foreign body deeper into the airway.

An obese client has limited mobility after an open reduction and internal fixation of a fractured hip. For which human response related to increased blood coagulability should the nurse monitor this client? A. Muscle deterioration B. Pain in the calf C. Hypotension D. Bradypnea

Answer: B A. Although muscle deterioration (atrophy) can occur with immobility, it is unrelated to hypercoagulability, Muscle atrophy is the decrease in the size of a muscle resulting from disease. B. Immobility promotes venous vasodilation, venous stasis, and hypercoagulability of the blood, which can precipitate the formation of a clot in a vein of the leg (venous thrombus) and inflammation of the vein (phlebitis). This results in pain. C. Hypotension, an abnormally low systolic blood pressure (less than 100 mm Hg), is not related to hypercoagulability precipitated by immobility. D. Bradypnea, abnormally slow breathing (less than 10 breaths per minute), is unrelated to hypercoagulability caused by immobility.

Which action is effective in meeting the needs of a client experiencing laryngospasm after extubation? A. Ensuring hyperextension of the head B. Providing positive-pressure ventilation C. Instituting cardiopulmonary resuscitation D. Administering oxygen by using a face mask

Answer: B A. Although tilting the head backward (hyperextension of the head) elongates the pharynx, reducing airway resistance, it will do nothing to correct the obstruction at the glottis (opening through the vocal cords). Also ,the tongue will block the airway unless there is forward pressure applied on the lower angle of the jaw (jaw thrust maneuver). B. Positive pressure will push the vocal cords backward toward the wall of the larynx, opening the glottis (space between the vocal cords), which allows ventilation of the lung. C. Instituting cardiopulmonary resuscitation is unnecessary. The client is having a respiratory, not a cardiac, problem. D. Administering oxygen by using a face mask is useless because the glottis is obstructed and the oxygenated air will not enter the lung.

A nurse hears a client explain the purpose of pursed-lip breathing to a relative. Which information would indicate to the nurse that the client correctly understood the nurse's teaching about pursed-lip breathing? A. Precipitates coughing B. Helps maintain open airways C. Decreases intrathoracic pressure D. Facilitates expectoration of mucus

Answer: B A. Deep breathing and huff coughing, not pursed-lip breathing, stimulate effective coughing. B. Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse. C. Pursed-lip breathing increases, not decreases, intrathoracic pressure. D. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word huff with short, forceful exhalations keeps the glottis open, mobilizes sputum, and stimulates a cough.

A meal tray arrives for a client who is receiving 24% oxygen via a Venturi mask. Which should the nurse do to meet this client's needs? A. Discontinue the oxygen when the client is eating meals. B. Request a prescription to use a nasal cannula during meals. C. Obtain a prescription to change the mask to a nonrebreather mask during meals. D. Arrange for liquid supplements that can be administered via a straw through a valve in the mask.

Answer: B A. Discontinuing oxygen when the client is eating is unsafe because it can compromise the client's respiratory status while the oxygen is disconnected. B. A Venturi mask interferes with eating because it covers the nose and mouth. Using a nasal cannula during meals will help meet both the nutritional and oxygen needs of the client. A nasal cannula delivers oxygen via prongs placed in the client's nares, leaving the mouth unobstructed, which promotes talking and eating. Specific oxygen delivery systems require a prescription, and their use is a dependent function of the nurse, except in emergency situations. C. A Venturi mask and a nonrebreather mask are both masks that cover the mouth, which interferes with eating. D. Liquid supplements are unnecessary. The client should eat the diet prescribed by the primary health-care provider.

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22-gauge needle. B. Select a site on the client's abdomen. C. Use the Z-track technique to displace the skin on the injection site. D. Observe for bleb formation to confirm proper placement.

Answer: B A. For a subcutaneous injection, the nurse should use a 25- to 27-gauge needle. B. Correct: For a subcutaneous injection, the nurse should select a site that has an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs). C. For a subcutaneous injection, the nurse should pinch the skin with her thumb and index finger. D. Bleb formation confirms injection into the dermis, not into subcutaneous tissue.

A nurse is preparing to administer a tablet to a client. When should the nurse remove the medication from its unit dose package? A. Outside the door to the client's room B. When next to the client's bed C. In the medication room D. At the medication cart

Answer: B A. Opening the package outside the room exposes the medication to the environment, where it may become contaminated or grouped with other medications being administered to the client, thus interfering with safe administration of one or more of the medications. B. The medication should be opened at the bedside and administered immediately to the client, thereby limiting the potential for contamination. Reading the label immediately before opening the package is an additional safety check. Immediate administration prevents accidental disarrangement of medications that may result in a medication error. C. Opening the package in the medication room exposes the medication to the environment because it requires the nurse to carry the medication through the unit to the client's room. In addition, it can become confused with the medications for other clients. D. Opening the package at the medication cart exposes the medication unnecessarily to the environment, and it can be inadvertently confused with the medications for other clients.

A nurse in the postanesthesia care unit is monitoring several clients who received general anesthesia. Which client response causes the most concern? A. Pain B. Stridor C. Lethargy D. Diaphoresis

Answer: B A. Pain is an expected response to the trauma of surgery and usually can be managed effectively. B. Stridor is an obvious audible, shrill, harsh sound caused by laryngeal obstruction. The larynx can become edematous because of the trauma of intubation associated with general anesthesia. Obstruction of the larynx is life-threatening because it prevents the exchange of gases between the lungs and the atmosphere. C. Lethargy, which is drowsiness or sluggishness, is an expected response to anesthesia and opioid medications because these medications depress the central nervous system. D. Although diaphoresis is a cause for concern, it is not as immediately life-threatening as an adaptation in another option. Diaphoresis can be related to a warm environment, impaired thermoregulation, the general adaptation syndrome, or shock.

Which information about a parenteral medication indicates that the nurse should use a filtered needle when preparing the medication? A. Has to be reconstituted B. Is supplied in an ampule C. Appears cloudy in the vial D. Is to be mixed with another medication

Answer: B A. Reconstitution occurs within a closed vial and does not require a filtered needle. B. The top of an ampule must be snapped off at its neck to access the fluid. A filtered needle prevents glass particles from being drawn into the syringe. C. The majority of medications in vials are clear solutions. Cloudy fluid usually indicates contamination. Additional information from a drug guide or a pharmacist is necessary to determine if the cloudiness is an expected characteristic of the drug or it indicates contamination. D. It is not necessary to use a filtered needle when mixing medications.

Answer: B A. Some medications, not fasting, cause metabolic tolerance as metabolism of the medication increases over time and the effectiveness of the medication declines. B. Correct: Inadequate nutrition, such as starvation, can affect the protein-binding response of medications. It increases their response and thus increases the risk for medication toxicity. C. Disorders that cause diarrhea, not fasting, cause oral medications to pass through the gastrointestinal tract too quickly for adequate absorption. This mechanism does not cause toxicity. D. Kidney disease or failure, not fasting, prevents or delays medication excretion, which can cause toxicity.

Which abbreviation indicates that the primary health-care provider wants a medication administered before meals? A. pc B. ac C. PO D. OD

Answer: B A. The abbreviation for after meals is pc (post cibum). B. The abbreviation for before meals is ac (ante cibum). C. The abbreviation for by mouth is PO (per os). D. The abbreviation for right eye is OD. However, this abbreviation should be spelled out because there is confusion among the following abbreviations: right eye--OD (oculus dexter), left eye--OS (oxulus sinister), and both eyes--OU (oculus utro).

4) A client is admitted with complaints of lower extremity edema and occasional shortness of breath. Which electrocardiogram finding supports that the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric

Answer: C

How often should "docusate sodium 100 mg PO bid" be given? A. Three times a day B. Two times a day C. Every other day D. At bedtime

Answer: B A. The abbreviation for three times a day is tid (ter in die). B. The abbreviation bid (bis in die) represents twice a day. C. Bid does not mean every other day. Every other day must be written out. The Joint Commission disallows the use of the abbreviation for every other day QOD (quaque altera die) because of the frequency of errors with its use. D. Bid (bis in die) represents twice a day, not at bedtime. Formerly, the abbreviation for bedtime (hour of sleep) was hs (hora somni); however, The Joint Commission disallows the use of the abbreviation of hs because of the frequency of errors with its use.

A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands? A. "I will straighten my ear canal by pulling my ear down and back." B. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal."

Answer: B A. The client should straighten his ear canal by pulling the auricle upward and outward to open up the ear canal and allow the medication to reach the eardrum. B. Correct: The client should gently apply pressure with the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal. C. The client should never occlude the ear canal with the dropper when instilling ear drops because this can cause pressure that could injure the eardrum. D. The client should not place a cotton ball past the outermost part of the ear canal because it could introduce bacteria to the inner or middle ear.

A nurse teaches a client how to use an incentive spirometer. Which projected client outcome supports the conclusion that the use of the incentive spirometer was effective? A. Expiratory volume will be decreased. B. Inspiratory volume will be increased. C. Sputum will be expectorated. D. Coughing will be stimulated.

Answer: B A. The expiratory volume should increase, not decrease, with the use of an incentive spirometer. B. An incentive spirometer provides a visual goal for and measurement of inspiration. It encourages the client to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis. C. Although sputum may be expectorated after the use of an incentive spirometer, this is not the primary reason for its use. D. Although the deep breathing associated with the use of an incentive spirometer may stimulate coughing, this is not the primary reason for its use.

A nurse, working in the emergency department, identifies that a client's hands are edematous when attempting to apply a pulse oximetry probe for a short-term use. Which action should the nurse implement? A. Attach the probe to one of the client's toes. B. Connect the probe to one of the client's earlobes. C. Wash the client's hand before attaching the probe to the finger. D. Encourage the client to perform active range-of-motion exercises of the hand with the probe.

Answer: B A. The use of a toe for pulse oximetry can result in inaccurate results because of concurrent problems, such as vasoconstriction, hypothermia, impaired peripheral circulation, and movement of the foot. B. An earlobe is an excellent site to monitor pulse oximetry. It is least affected by decreased blood flow, has greater accuracy at lower saturations, and rarely is edematous. This site is used for intermittent, not continuous, monitoring. C. Soap and water will not resolve edema. In addition, attaching a pulse oximeter clip sensor to an edematous finger is contraindicated because interstitial fluid interferes with obtaining an accurate oxygen saturation level. D. The cause of the edema must be identified first because range-of-motion exercises may be contraindicated.

A primary health-care provider prescribes chest physiotherapy with percussion and vibration for a newly admitted client. Which information obtained by the nurse during the health history should alert the nurse to question the provider's prescription? A. Emphysema B. Osteoporosis C. Cystic fibrosis D. Chronic bronchitis

Answer: B A. These are appropriate interventions for a client with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls. B. Implementing the primary health-care provider's prescription may compromise client safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. C. These are appropriate interventions for a client with cystic fibrosis. Cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick, tenacious secretions in the respiratory system that block the bronchioles, creating breathing difficulties. D. These are appropriate interventions for a client with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways.

A nurse is working with a newly licensed nurse who is administering medication to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? A. Taking all medications out of the unit-dose wrappers before entering the client's room. B. Checking with the provider when a single dose requires administration of multiple tablets. C. Administering a medication, then looking up the usual dosage range. D. Relying on another nurse to clarify a medication prescription.

Answer: B A. To prevent errors, the nurse should not take unit-dose medications out of wrappers until at the bedside when performing the third check of medication administration. The nurse can encourage clients' involvement and provide teaching at this time. B. Correct: If a single dose requires multiple tablets, it is possible that an error has occurred in the prescription or transcription of the medication. This action could prevent a medication error. C. Reviewing the usual dosage range prior to administration can help the nurse identify in inaccurate dosage. D. If the prescription is unclear, the nurse should contact the provider, not another nurse, for clarification.

The nurse is assessing a group of patients. Which patient should the nurse consider to be at the greatest risk for an alteration in oxygenation? A. A 62-year-old patient B. A 67-year-old patient C. A 2-year-old child D. A 22-year-old patient

Answer: B Although the inability to oxygenate properly can occur at any point during the lifespan, very young children (less than 1 year of age) and older adults (over the age of 65) are at increased risk for alterations in oxygenation. Very young children are more susceptible to respiratory disorders that affect oxygenation. Older adults carry an increased risk of developing a variety of health impairments, such as respiratory or cardiac diseases that can affect oxygenation. The 2-year-old, 22-year-old, and 62-year-old patients are not in the age groups at increased risk.

A patient presents with chest congestion and a cough. Which skill should the nurse expect to use to specifically assess for chest congestion? A. Palpation and percussion B. Percussion and auscultation C. Inspection and palpation D. Auscultation and inspection

Answer: B An adult reporting chest congestion must be thoroughly assessed to determine if the congestion is upper respiratory or cardiac in origin. Percussion is helpful in assessing density or fluid-filled spaces, and auscultation assesses the air exchanged during a respiratory cycle. The combination of percussion and auscultation would make for a complete assessment of the lungs when a patient complains of chest congestion.

Which cause of an alteration in oxygenation should the nurse consider to be a nonmodifiable risk factor? A. Cardiovascular disease B. Hemoglobin disorder C. Cigarette smoke D. Obesity

Answer: B Hemoglobin concentration affects oxygenation and is considered a nonmodifiable risk factor for alterations in oxygenation. Cigarette smoking, obesity, and cardiovascular disease are all considered modifiable risk factors for alterations in oxygenation.

The nurse is caring for an older adult with a decreased gag reflex. Which nursing intervention is a priority? A. Administer anticholinergic medications as ordered. B. Have suction equipment available. C. Encourage use of incentive spirometer hourly. D. Administer oxygen at 1 L/min as ordered.

Answer: B Older adults with decreased gag and cough reflexes are susceptible to aspiration of secretions. Therefore, they may need suctioning. Administration of oxygen and use of incentive spirometry will not affect the gag reflex. The administration of an anticholinergic medication may decrease bronchospasm, but it will not improve the gag reflex.

Which breathing difficulty should the nurse understand is associated with body position? A. Hypoxia B. Orthopnea C. Tachypnea D. Apnea

Answer: B Orthopnea is difficulty breathing when supine. Tachypnea is rapid breathing. Apnea is the absence of respirations. Hypoxia is a low amount of oxygen in the bloodstream. Tachypnea, apnea, and hypoxia are not influenced by body position.

A patient who has been receiving intravenous fluids to increase perfusion now has crackles in the lungs. Which action should the nurse perform first? A. Obtain arterial blood gases (ABGs). B. Place the patient in high Fowler position. C. Administer the ordered short-acting beta-agonist (SABA). D. Administer oxygen to the patient.

Answer: B Positioning affects oxygenation, and the high Fowler position may benefit individuals experiencing fluid buildup in the lungs. Oxygen and ABGs may be needed if the lung function deteriorates further. A SABA is not needed, as this is not a broncho-constriction problem.

Which is the nurse doing when using the interviewing technique of attentive listening? A. Identifying the client's concerns and exploring them with "why" questions B. Determining the content and feeling of the client's message D. Using verbal skills to obtain information

Answer: B Rationale: A. "Why" statements are direct questions that tend to put the client on the defensive and cut off communication. B. Attentive listening is the active use of all the senses to comprehend and appreciate the client's verbal and nonverbal thoughts and feelings. C. Silence is a passive interaction. Silence allows the client time for quiet contemplation of what has been discussed. D. Using verbal skills to obtain information is an interview. The nurse is talking instead of listening.

Which statement describes the following proverb? What you do speaks so loudly I cannot hear what you say. A. Hearing ability is an important factor in communicating. B. Nonverbal messages are often more meaningful than words. C. Listening to what people say requires attention to what is being said. D. When people talk too loudly, it is hard to understand what is being said.

Answer: B Rationale: A. Although hearing, one aspect of decoding a message, is an important factor in the communication process, it is unrelated to the stated proverb. B. Nonverbal communication (e.g., body language) conveys messages without words and is under less conscious control than verbal statements. When a person's words and behavior are incongruent, nonverbal behavior most likely reflects the person's true feelings. C. Although this true statement reflects active listening, it is unrelated to the stated proverb. D. This statement is unrelated to the stated proverb. The volume of a message may or may not influence understanding of the message. The volume of a message occurs on the physiological level, whereas understanding a message occurs on the cognitive level.

A nurse is caring for a variety of clients, each experiencing one of the following problems. Which health problem places a client at the highest risk for complications associated with immobility? A. Incontinence B Quadriplegia C. Hemiparesis D. Confusion

Answer: B Rationale: A. Clients who are incontinent are not necessarily immobile. B. Quadriplegia, paralysis of all four extremities, places the client at highest risk for pressure ulcers because the client has no ability to shift body weight off of bony prominences or change position without total assistance. C. Hemiparesis, muscle weakness on one side of the body, does not prevent a person from shifting or changing position to relive pressure on the skin. D. Confused clients can move independently when uncomfortable or when encouraged and assisted to move by the nurse.

A client has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility that may be associated with this client is a concern for the nurse? A. Dehydration B. Contractures C. Incontinence D. Hypertension

Answer: B Rationale: A. Dehydration is not a response to immobility. B. Contractures can result from permanent shortening of muscles, tendons, and ligaments and are a complication associated with a brain attack if routine range-of-motion exercises and maintaining the body in functional alignment are not provided. C. The decreased tone of the urinary bladder and the inability to assume the usual voiding position in bed promote urinary retention, rather than urinary incontinence. D. With immobility, the increased heart rate reduces the diastolic pressure. In addition, there is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). This situation is manageable with a priority on maintaining client safety.

8) A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8 hours. What should the nurse do to assist this client? A) Assist the client to ambulate. B) This is a normal urine output and the client does not need anything. C) Notify the physician, as the client could be dehydrated. D) Measure abdominal girth as a true assessment of the client's fluid status.

Answer: C

9) A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. The nurse will include all except: A) Dilated. B) Restrictive. C) Hypotrophic. D) Arrythmogenic right ventricular.

Answer: C

A client appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today." Which interviewing approach did the nurse use? A. Examining B. Reflecting C. Clarifying D. Orienting

Answer: B Rationale: A. Examining is not an interviewing technique. B. Reflective technique refers to feelings implied in the content of verbal communication or in exhibited nonverbal behaviors. Clients who are crying, quiet, and withdrawn often are sad. C. This is not an example of clarifying, which is the use of a statement to understand a message better when communication is unclear, rambling, or garbled. D. This is not an example of orienting. Reality orientation is a nursing technique used to assist clients in restoring an awareness of what is actual, authentic, or real.

A nurse is developing a therapeutic relationship with a client with emotional needs. Which nursing intervention is essential during the working stage of the relationship? A. Establish a formal or informal contract that addresses the client's problems. B. Implement nursing actions that are designed to achieve expected client outcomes. C. Develop rapport and trust so the client feels protected and an initial plan can be identified. D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.

Answer: B Rationale: A. Formal or informal contracts are established during the introductory (orientation), not working, stage of a therapeutic relationship. B. During the working stage of the therapeutic relationship, nursing interventions have a twofold purpose: assisting clients to explore and understand their thoughts and feelings and facilitating and supporting clients' decisions and actions. Both of these help the client achieve expected outcomes. C. The development of trust is the primary goal of the introductory (orientation), not working, stage of a therapeutic relationship. Trust is achieved through respect, concern, credibility, and reliability. D. These tasks are achieved during the introductory (orientation), not working, stage of a therapeutic relationship.

A nurse identifies that a client's pressure ulcer has just partial-thickness skin loss involving the epidermis and dermis. Which stage pressure ulcer should the nurse document based on this assessment? A. Stage I B. Stage II C. Stage III D. Stage IV

Answer: B Rationale: A. In a stage I pressure ulcer, the skin is still intact and manifests clinically as reactive hyperemia. B. In a stage II pressure ulcer, the partial-thickness skin loss manifests clinically as an abrasion, blister, or shallow crater. C. In a stage III pressure ulcer, there is full-thickness skin loss involving the subcutaneous tissue that may extend to the underlying fascia. The ulcer manifests clinically as a deep crater with or without undermining. D. In a stage IV pressure ulcer, there is full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

A nurse is caring for a client with impaired mobility. Which position contributes most to the formation of a hip flexion contracture? A. Low-Fowler B. Orthopneic C. Supine D. Sims

Answer: B Rationale: A. In the low-Fowler position, the hips are slightly flexed. B. While in the high-Fowler position, the client is then positioned leaning forward with the arms resting on an over-bed table (orthopneic position). In the orthopneic position, the hips are extensively flexed, creating an angle of less than 90 degrees. C. In the supine position, the hips are extended (180 degrees), not flexed. D. In the Sims position, the hip and the knee of the upper leg are just slightly flexed.

A client has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the client active range-of-motion exercises. Which client action indicates that further teaching is necessary? A. Moves the elbow to the point of resistance B. Keeps 90° elbow flexion after the prcoedure C. Assesses the elbow's response after this procedure D. Puts the elbow through its full range at least 3 times

Answer: B Rationale: A. Moving the elbow to the point of resistance is desirable. Performing range-of-motion exercises beyond resistance may injure muscles and joints and should be avoided. B. Keeping the elbow flexed after the procedures is undesirable because it contributes to a flexion contracture. Slight flexion to maintain functional alignment is preferred because it minimizes stress and strain on muscle, tendons, ligaments, and joints. C. Responses to range-of-motion exercises must be evaluated and compared with the assessment performed before the procedure. D. Sequential flexion and extension of a hinge joint are efficient in facilitating full range of motion of the joint.

A nurse plans to foster a therapeutic relationship with a client. Which is important for the nurse to do? A. Sympathize with the client when the client communicates sad feelings. B. Demonstrate respect when discussing emotionally charged subjects. C. Use humor to defuse emotionally charged topics of discussion. D. Work on establishing a friendship with the client.

Answer: B Rationale: A. Sympathy denotes pity, which should be avoided. The nurse should empathize, not sympathize, with the client. B. Emotionally charged topics should be approached with respectful, sincere interactions that are accepting and nonjudgmental and that will promote further expression of feelings. C. Humor with emotionally charged issues may be viewed as minimizing concerns or being frivolous and could be a barrier to communication. D. The nurse should maintain a professional relationship with the client. Nurses may be "friendly" toward clients but should not establish a "friendship" with a client.

An emaciated client is at risk for developing a pressure ulcer. In which position should the nurse avoid placing the client? A. Thirty-degree lateral position B. Side-lying position C. Supine position D. Prone position

Answer: B Rationale: A. The 30-degree lateral position is the preferred position to prevent pressure ulcers because it limits body weight directly over bony prominences, versus other positions. B. In the side-lying position, the majority of the body weight is borne by the greater trochanter. The bone is close to the surface of the skin, with minimal overlying protective tissue. C. In the supine position, the occiput, scapulae, spine, elbows, sacrum, and heels are at risk for pressure; however, the body weight is distributed more evenly than in some other positions. D. In the prone position, the ears, cheeks, acromion process, anterior-superior spinous process, knees, toes, male genitalia, and female breasts are at risk for pressure; however, the body weight is distributed more evenly than in some other positions.

Which structural difference should the nurse expect when assessing a preschooler compared to an adult patient? A. Atrophy of the tonsils B. More functional muscles C. Short epiglottis D. Narrow nasopharynx

Answer: D The nasopharynx is smaller and narrower in pediatric patients. When assessing a preschool-age patient's respiratory system, the nurse expects to find a long, floppy epiglottis. Enlarged tonsils are expected, and atrophy does not occur until the age of 12 years. Pediatric patients have fewer functional muscles for respiration.

A client who has had postoperative complications appears upset and agitated yet withdrawn. Which is the most appropriate statement by the nurse? A. "You seem distressed. Tell me why you are upset." B. "You've been having a pretty rough time recovering since surgery" C. "It's not uncommon to have complications after the kind of surgery that you had." D. "I'm not sure that I know everything that has been happening. Tell me what has happened to you since surgery."

Answer: B Rationale: A. The first part of this statement uses the therapeutic interviewing technique of reflection, which identifies the underlying feelings of the client and is appropriate. However, the second half of the statement is asking for an explanation, which is inappropriate. Clients often interpret "why" questions as accusations, which can cause resentment and mistrust and should be avoided. B. This is an example of the therapeutic interviewing skill of an open-ended statement. It demonstrates that the nurse recognizes what the client is going through, and the statement encourages the client's expression of feelings. At the very least, it demonstrates caring and concern. C. This statement minimizes the client's feelings and is not supportive. D. This statement will not inspire confidence in the nurse. Nurses should know what is happening if care is to be comprehensive and client centered.

Which stage of an interview establishes the relationship between the nurse and the client? A. Preinteraction stage B. Orientation stage C. Examining stage D. Working stage

Answer: B Rationale: A. The preinteraction stage occurs before the nurse meets the client. During this stage, the nurse gathers information about the client. B. The purposes of the orientation stage of an interview are to establish rapport and orient the interviewee. A relationship is established through a process of creating goodwill and trust. The orientation stage focuses on explaining the purpose and nature of the interview and what is expected of the client. C. There is no stage called the examining stage in an interview. Examining takes place during a physical assessment, when specific skills are used to collect data systematically to identify health problems. D. This is not the purpose of the working stage. In the working stage (also called the body stage) of an interview, clients communicate how they think, feel, know, and perceive in response to questions by the nurse.

An agitated 80-year-old client states, "I'm having trouble with my bowels." Which response by the nurse incorporates the interviewing skill of paraphrasing? Select all that apply. A. "Tell me what you mean by having trouble." B. "It sounds like your bowels are causing you problems." C. "You sound upset that your bowels are causing difficulties." D. "It's common to have problems with your bowels at your age." E. "When did you first notice having trouble with your bowels?"

Answer: B Rationale: A. This response is an example of clarification. The nurse wants the client to elaborate in an effort to obtain more information about the word "trouble." B. The nurse's statement substitutes the word problems for trouble, which paraphrases the client's comment. C. This is not an example of paraphrasing. This statement uses the interviewing technique of reflection because it focuses on feelings rather than words. D. This negates the client's concern and shuts off communication. E. This is not an example of paraphrasing; it is a direct question (focused assessment) that collects specific information.

A nurse is making an occupied bed. Which is the easiest way for the nurse to prevent plantar flexion? A. Tuck in the top linens on just the sides of the bed. B. Place a toe pleat in the top linens over the feet. C. Let the top linens hang off the end of the bed. D. Position the top linens over a bed cradle.

Answer: B Rationale: A. Top sheets tucked in along the sides of the bed still exert pressure on the upper surface of the feet, which may promote plantar flexion. The sides of top sheets, mitered at the foot of the bed, hang freely off the side of the bed. B. Making a vertical or horizontal toe pleat in the linen at the foot of the bed over the client's feet leaves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus minimizing plantar flexion. C. The weight of the top sheets still exerts pressure on the upper surface of the feet, promoting plantar flexion. D. Although the use of a bed cradle will hold the linen off the legs and feet of the client, it is not the easiest way for the nurse to prevent plantar flexion of the options presented.

The nurse will not crush the extended-release medications ordered for her client because: A. They are very distasteful, and this reduces client compliance. B. Crushing alters the rate of absorption and medication delivery. C. Multiple drug pieces cause obstructive symptoms. D. Crushed oral medications have reduced bioavailability.

Answer: B Rationale: Crushing medications that are developed/manufactured to be extended release (ER) alters the way the medication is delivered and absorbed by the body. ER medications are not necessarily distasteful when crushed (option 1), In addition, when taken orally, crushing these medications should not cause obstructions (option 3). (Option 4), unless contraindicated, such as in ER medications, some oral medications can be crushed without affecting bioavailability.

The client informs the nurse that he uses herbal compounds given by a family member to treat his hypertension. What is the most appropriate action by the nurse? A. Inform the client that the herbal treatments will be ineffective. B. Obtain more information and determine whether the herbs are compatible with medications prescribed. C. Notify the health care provider immediately. D. Inform the client that the health care provider will not treat him if he does not accept the use of traditional medicine only.

Answer: B Rationale: Many cultural groups believe in using herbs and other alternative therapies either along with or in place of traditional medicines. The nurse should interpret how these herbal and alternative therapies will affect the desired pharmacotherapeutic outcomes. Options 1, 3, and 4 are incorrect. Herbal therapies may be effective in the treatment of disease conditions but may interact with traditional medicines. It is not necessary to notify the provider immediately unless the client's symptoms warrant such an urgency. The provider should be made aware of the client's desire to use herbal therapies, but this is not a reason that a provider would refuse to continue health care for this client. Cognitive Level: Applying. Nursing Process: Assessment. Client Need: Health Promotion and Maintenance.

The size of the syringe, for an injectable medicine, relates to A. The size of the needle B. The volume of the injectable medicine ordered C. The original provider's order D. The assessment of the patient's site

Answer: B Rationale: The syringe I choose depends on the volume of a drug. If I am giving less than 1 mL then a TB (1mL) syringe would be the best choice. The needle size depends on the route and assessment of the patient. Although the provider will provide the dose of the medication, the volume of the med that will be drawn up depends on the 'strength' of the medication, written on the vial. Remember our example in class - Vistaril can come in 50 mg/mL or 100 mg/mL

The client informs the nurse that she will decide whether she will accept treatment after she prays with her family and minister. What is the role of spirituality in drug therapy for this client? A. Irrelevant because medications act on scientific principles B. Important to the client's acceptance of medical treatment and response to treatment C. Harmless if it makes the client feel better D. Harmful, especially if treatment is delayed

Answer: B Rationale: When clients have strong spiritual or religious beliefs, these may greatly influence their perceptions of illness and their preferred modes of treatment. Ill health and spiritual issues can have an impact on wellness, nursing care, and pharmacotherapy. Options 1, 3, and 4 are incorrect. Recognizing the role that spirituality plays in a client's life is important to treating the client holistically. Even if treatment is delayed, it may cause greater harm to force a medication on the client than to wait. Cognitive Level: Analyzing. Nursing Process: Assessment. Client Need: Psychosocial Integrity.

A patient is seen in the emergency department complaining of chest pain. Which question is the nurse most likely to ask immediately upon seeing the patient in triage? A. "Have you recently lost a significant amount of weight?" B. "Where is your chest pain located?" C. "Are you a smoker?" D. "What is your diet like?"

Answer: B The first question that the nurse will likely ask the patient is where the chest pain is located. Questions about lifestyle, such as status as a smoker, diet, and/or recent weight loss, may follow after the nurse has determined where the chest pain is, how it feels, and the timing and nature of the pain.

A patient with respiratory distress is showing signs of decreasing cardiac output and hypoxemia. Which action should the nurse take first? A. Assess pulmonary function. B. Administer oxygen via face mask. C. Assess the nail beds for cyanosis. D. Assess the patient's arterial blood gases.

Answer: B With signs of hypoxemia, oxygen via face mask should be administered first. Pulmonary function can be assessed after oxygenation is restored. Assessment of the nail beds for cyanosis and arterial blood gases are not the first actions due to signs of hypoxemia being seen already.

A client is prescribed cardiac rehabilitation and asks why it is necessary. Which response by the nurse expresses the goals of this program? A. "Your blood pressure is elevated and this program will help to decrease your blood pressure and reduce your risk of having a heart attack." B. "Because you have had a cardiac injury, this program will provide the opportunity for your heart to reach optimal function." C. "You have been diagnosed with congestive heart failure (CHF) and this program will help improve the amount of blood and oxygen distributed to your muscles." D. "As you go through cardiac rehabilitation, you will gradually regenerate cardiac muscle tissue that will improve your heart function."

Answer: B Rationale: Cardiac rehabilitation is a medically supervised program of exercise and lifestyle modification that aids people who have had a cardiac injury due to myocardial infarction (MI), heart failure, heart surgery, or interventional cardiology to maintain optimal cardiac function in the remaining heart tissue. Cardiac rehabilitation is recommended for anyone who has had a heart attack, and it can help individuals resume a high quality of life after cardiac injury.

A client asks the nurse about the purpose of incentive spirometry. Which information should the nurse include in the explanation? A. Prevents lung collapse B. Clears mucus secretions C. Decreases oxygen demand D. Increases lung volume

Answer: B Rationale: Incentive spirometry is a breathing exercise using an incentive spirometer that helps clients breathe deeply to expand the lungs. This process can help clients clear mucus secretions and increase the amount of oxygen delivered to the bronchi and alveoli. Incentive spirometry does not decrease oxygen demand or increase lung volume. It may prevent collapse of the alveoli, but not the lungs.

A client has crackles and reports increasing shortness of breath. Which action should the nurse take first? A. Administer a bronchodilator. B. Place the client in high Fowler position. C. Assess the respiratory rate. D. Apply oxygen to the client.

Answer: B Rationale: Positioning affects oxygenation, and the high Fowler position may benefit individuals experiencing alterations in oxygenation by moving fluid to the bases and allowing for increased lung expansion. A bronchodilator is used when bronchoconstriction is a concern for oxygenation. Oxygen may be used, but position change will have a more immediate impact. Assessment of the respiratory rate may be done, but after the position is changed.

A client diagnosed with bronchitis asks the nurse about the function of the bronchi. Which should the nurse include in the response? A. Contain the heart, trachea, esophagus, and the great vessels B. Warm and moisten air as it moves through the respiratory tract to the alveoli C. Help to keep the lungs inflated D. Capture and help sweep the debris toward the mouth for removal when coughing

Answer: B Rationale: The function of the bronchi is to warm and moisten the air as it moves through the respiratory tract to the alveoli in the lungs. The mediastinum contains the heart, trachea, esophagus, a portion of the right and left main bronchi, and the great vessels. Cilia within the trachea capture debris and help to sweep the debris toward the mouth for removal when coughing. Surface tension, created by fluid and negative pressure, keeps the lungs inflated.

The nurse is planning care for a client who is receiving oxygen. Which intervention should the nurse include? A. Increase the oxygen flow if the client requests. B. Ensure the client is comfortable with the manner of administration. C. Assess the client for anxiety. D. Suction upper airways each shift.

Answer: B Rationale: The nurse ensures that the client is comfortable with the manner in which the oxygen is being administered. There are several choices, and the client should be consulted in terms of which method is most comfortable. The nurse should not increase the flow of oxygen at the client's request, because the healthcare provider prescribes the flow. Clients who are prescribed oxygen are at risk for depression, not anxiety. Suctioning the upper airway should only be done as required, if at all.

A client recovering from surgery begins to have an increase in body temperature and carbon dioxide level. What should the nurse do first? A) Assess for patent intravenous line. B) Provide 100% oxygen with a nonrebreather mask. C) Provide dantrolene. D) Contact the anesthesiologist.

Answer: B Explanation: An increase in body temperature and carbon dioxide level are indications that the client is developing malignant hyperthermia. The first thing the nurse should do is apply 100% oxygen with a nonrebreather mask. The nurse should then ensure good intravenous access and contact the anesthesiologist. The anesthesiologist will prescribe dantrolene for administration.

A client with a newly created colostomy wants to learn how to irrigate the colostomy. The nurse provides this teaching by developing a therapeutic nurse-client relationship and implementing teaching strategies. Identify the statement that is included in the working stage of this therapeutic relationship. Select all that apply. A. "How do you feel about doing this procedure?" B. "Would you like to try to insert the cone yourself today?" C. "You did a great job managing the instillation of fluid today." D. "I am here to help you learn how to irrigate your colostomy." E. "I'll arrange for a home-care nurse to visit you in your home when you are discharged."

Answer: B, C Rationale: A. This statement reflects the orientation stages of a therapeutic relationship. Although exploration of feelings is done throughout the stages, the primary goal of the orientation stage is the establishment of trust. Trust is promoted when the nurse focuses on the client's emotional needs, is respectful, and individualizes care. B. This statement reflects the working stage of a therapeutic relationship. It involves completing interventions that address expected outcomes, such as learning how to perform a colostomy irrigation. C. This statement reflects the working stage of a therapeutic relationship. It includes providing feedback and encouragement. D. This statement reflects the orientation stage of a therapeutic relationship. The nurse and the client make a verbal agreement to work together to assist the client to achieve a goal. E. This statement reflects the termination stage of a therapeutic relationship. It focuses on summarizing what has transpired and been accomplished and looks to the future.

Answer: B, C, D A. Children have decreased gastric acid production. B. Correct: Children have a lower blood pressure. C. Correct: Children have a higher body water content. D. Correct: Children have increased absorption of topical medications. E. Children have a slower gastric emptying time.

Answer: B, C, D A. The provider adjusts the client's dosages. Instructing the client to base dosages on daily weight increases the risk for error in medication self-administration. B. Correct: Organizing medications in daily pill holder promotes medication adherence. C. Correct: Providing a form of medication that is easier for the client to swallow promotes medication adherence. D. Correct: Including the client's support system promotes medication adherence. E. Some older adult clients have difficulty opening child-resistant caps. Request easy-open containers from the pharmacy.

A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test(s) will the nurse expect the client to have performed? Select all that apply. A) CT scan of the abdomen B) Chest x-ray C) Urinalysis D) Complete blood count E) Bone scan

Answer: B, C, D Explanation: The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells. The urinalysis will be done to see if the client has a urinary tract infection. The chest x-ray will be done to see if the client has a lung infection. A bone scan and CT scan of the abdomen may or may not be indicated for this client.

The nurse is performing a respiratory assessment on a young adult. Which finding is considered an alteration of oxygenation? (Select all that apply.) A. Eupnea B. Orthopnea C. Tachypnea D. Retractions E. Dyspnea

Answer: B, C, D, E Rationale: Alterations of oxygenation are manifested by dyspnea, orthopnea, tachypnea, and retractions. Eupnea, or normal breathing, is not a finding that indicates an alteration in oxygenation.

Which systemic response in immobilized clients should nurses monitor for? Select all that apply. A. Pressure ulcer B. Dependent edema C. Hypostatic pneumonia D. Plantar flexion contracture E. Increased cardiac workload

Answer: B, C, E Rationale: A. Prolonged pressure on skin over a bony prominence interferes with capillary blood flow to the skin, which ultimately can result in a pressure ulcer. A pressure ulcer is a localized, not systemic, response to immobility. B. Decreased calf muscle activity and pressure of the bed on the legs allow blood to accumulate in the distal veins. The resulting increased hydrostatic pressure moves fluid out of the intravascular compartment and into the interstitial compartment, causing edema. Dependent edema is a systemic response to immobility. C. Static respiratory secretions provide an excellent media for bacterial growth that can result in hypostatic pneumonia, which is a systemic response to immobility. D. Plantar flexion contracture (footdrop) is a localized response to prolonged extension of the ankle. E. An increased cardiac workload results from a decrease in vessel resistance and redistribution of blood in the body, with blood pooling in the lower extremities. These are systemic responses to immobility.

While taking the client's admission history, the client describes having a severe allergy to an antibiotic. What is the nurse's responsibility to prevent an allergic reaction? (Select all that apply.) A. Instruct the client to alert all providers about the allergy. B. Document the allergy in the medical record. C. Notify the provider and the pharmacy of the allergy and type of allergic reaction. D. Place an allergy bracelet on the client. E. Instruct the client not to allow anyone to give the antibiotic.

Answer: B, C, E Rationale: Documenting the allergy in the medical record, notifying the provider and the pharmacy about the allergy and type of response, and applying an allergy alert band are all responsibilities of the nurse. Options 1 and 5 are incorrect. Although the client should notify all health care personnel of the allergy, there may be times when the client cannot communicate this information or forgets. It is the nurse's responsibility to communicate the allergy so that the drug is not given. Cognitive Level: Analyzing. Nursing Process: Implementation. Client Need: Safe and Effective Care Environment.

The nurse is presenting issues related to alterations in mobility with a group of community members. Which major risk factor should the nurse include? A. Genetics B. Aging C. Gender D. Fluid level

B The major risk factor for an alteration in mobility is aging. Gender and fluid level are not identified as major risk factors for an alteration in mobility. Genetic disorders can cause mobility issues; however, they are not a major risk factor for the development of mobility alterations.

Which of the following medications would not be administered through a nasogastric tube? (Select all that apply.) A. Liquids B. Enteric-coated tablets C. Sustained-release tablets D. Finely crushed tablets E. IV medications

Answer: B, C, E Rationale: Enteric-coated tablets are designed to dissolve in the alkaline environment of the small intestine. Sustained-release medications dissolve very slowly over an extended period for a longer duration. Crushing either of these types of medications will alter the absorption. IV medications are designed to enter directly into the bloodstream and, while liquid, may be in a different dosage form or concentration that is not compatible with other types of administration. Liquid forms or finely crushed tablets are the preferred forms to use for nasogastric administration. Cognitive Level: Applying. Nursing Process: Implementation. Client Need: Safe and Effective Care Environment.

A surgical client is admitted to the ICU following abdominal surgery. Which clinical manifestation would the nurse recognize as an indication of decreased cardiac output? (Select all that apply.) A. Capillary refill <3 seconds B. Decreased urine output C. Lethargy D. Palpable pedal pulses E. Increased pulse rate

Answer: B, C, E Rationale: Indicators of decreased cardiac output include poor skin turgor, altered mental status, and decreased urine output. Cardiac output is determined by heart rate, preload, afterload, and contractility. A decrease in circulating blood volume results in decreased venous return and therefore decreased preload. A decreased preload reduces stroke volume and leads to decreased cardiac output. Pulse rates usually increase to compensate for decreased volume to stabilize cardiac output. Palpable pedal pulses and capillary refill <3 seconds are normal findings.

The nurse is caring for a client with a chest tube. Which intervention should the nurse implement? (Select all that apply.) A. Prescribe pain medications as needed. B. Assess for pain. C. Ensure oxygen is available. D. Report hyperresonance with percussion. E. Monitor for air leaks.

Answer: B, C, E Rationale: When caring for a client with a chest tube, the nurse would ensure that oxygen is available, monitor tubing for air leaks, and assess for pain. The nurse would not report hyperresonance with percussion but would report tympany, or a hollow sound. It is outside the scope of nursing practice to prescribe pain medications.

Which intervention is uniquely related to the administration of an intradermal injection? Select all that apply. A. Using the air-bubble technique B. Circling the injection site with a pen C. Pinching the skin during needle insertion D. Inserting the needle with the bevel upward E. Massaging the area after the fluid is instilled

Answer: B, D A. The air-bubble or air-lock technique can be used with intramuscular, not intradermal, injections. B. Circling the injection site with a pen indicates the area that must be evaluated; generally, the site is assessed 72 hours after the intradermal injection. C. Pinching or bunching up tissue is appropriate with subcutaneous, not intradermal, injections. D. When medication is injected with the bevel up, a small wheal will form under the skin. This technique is used only with intradermal injections. E. Massaging the site of an intradermal injection will disperse the medication beyond the intended injection site and is contraindicated.

A nurse is assessing a client to determine if it is appropriate to administer a prescribed medication via the oral route. Which information indicates that the nurse should ask the primary health-care provider for a change in route? Select all that apply. A. Nausea B. Unconsciousness C. Gastric suctioning D. Emergency situation E. Difficulty swallowing

Answer: B, D A. Vomiting, not nausea, is a contraindication for oral medications. B. Nothing that requires swallowing should ever be placed into the mouth of an unconscious client because of the risk for aspiration. C. Gastric suctioning can be interrupted for 20 to 30 minutes after medication has been instilled via a nasogastric tube. D. In an emergency, a drug is best administered IV, rather than orally, because it is faster acting. E. Nursing interventions, such as positioning, mixing a crushed medication in applesauce, and dissolving a medication in a small amount of fluid, can be employed to facilitate the ingestion of medication.

The nurse is planning to instruct a new mother on ways to prevent hypothermia in her newborn. What should this teaching include? Select all that apply. A) Expect the baby to shiver. B) Keep the newborn's head covered. C) Cover the newborn with a light sheet during afternoon naps. D) Notice changes in the baby's respirations and take the appropriate action. E) Cover the newborn with minimal blankets when out of doors in temperatures in the 50s.

Answer: B, D Explanation: Chilling can cause signs of respiratory distress in the newborn. The nurse should instruct the mother to be aware of changes in respirations, which would indicated that the baby is cold and needs to be protected. Covering the newborn's head will also reduce heat loss. The newborn should be covered with more than a light sheet during afternoon naps. The newborn should be protected with many blankets when out of doors in temperatures in the 50s. Shivering is not expected and means that the baby's metabolic rate has doubled.

A primary health-care provider prescribes a liquid oral medication for a client. Which action should the nurse implement when administering this medication? Select all that apply. A. Vigorously shake the liquid before pouring a dose. B. Measure oral liquids in a calibrated medication cup at eye level. C. Pour liquids with the label facing away from the palm of the hand. D. Place an opened top of a container on a surface with the inside lid facing up. E. Use a needleless syringe to measure a oral liquid less than 5 mL and transfer it to a medication cup.

Answer: B, D, E A. Not all liquids should be vigorously shaken. Only liquids that contain constituents that must be evenly distributed need to be vigorously shaken; the nurse should follow the manufacturer's directions. B. Measuring oral liquids in a calibrated medication cup at eye level ensures accuracy of the dose. C. Liquids should be poured with the label against the palm of the hand to prevent the liquid from dripping on and obscuring the label. D. Placing an opened top of a container on a surface with the inside lid facing up prevents contamination of the inside of the lid and subsequent contamination of the bottle when the lid is returned and closed. E. Using a needleless syringe to measure an oral liquid volume less than 5 mL and transferring it to a medication cup are acceptable practices because they ensure accuracy of the dose.

A nurse is caring for a client with thrombophlebitis. For which of the following clinical manifestations of a complication associated with thrombophlebitis should the nurse monitor the client? Select all that apply. A. Postural hypotension B. Difficulty breathing C. Blanchable erythema D. Dependent edema E. Acute chest pain

Answer: B, E A. Postural hypotension is unrelated to thrombophlebitis. Postural hypotension (orthostatic hypotension) is a decrease in blood pressure related to positional or postural changes from the lying down to sitting or standing positions. B. Dyspnea is a clinical manifestation of a pulmonary embolus, a life-threatening condition. A thrombus that breaks loose from a vein wall and travels through the circulation (embolus) eventually will obstruct a pulmonary artery or one of its branches (pulmonary embolus). C. Blanchable erythema is unrelated to thrombophlebitis. Blanchable erythema (reactive hyperemia) is a reddened area caused by localized vasodilation in response to lack of blood flow to the underlying tissue. The reddened area will turn pale with fingertip pressure. D. Dependent edema is unrelated to thrombophlebitis. Although fluid will collect in the interstitial compartment (edema) around a thrombophlebitis, it is localized, not dependent, edema. Dependent edema is the collection of fluid in the interstitial tissues below the level of the heart; it occurs bilaterally and usually is caused by cardiopulmonary problems. E. Immobility promotes venous stasis, which, in conjunction with hypercoagulability and injury to vessel walls, predisposes clients to thrombophlebitis. These three factors are known as Virchow's triad. A thrombus can break loose from the vein wall and travel through the circulation (embolus), where eventually it obstructs a pulmonary artery or one of its branches and causes sudden, acute chest pain, dyspnea, coughing, and frothy sputum.

10) A client with cardiomyopathy is experiencing tachycardia. Which medication order does the client's nurse anticipate? A) ACE Inhibitor B) Angiotensin II receptor blocker C) Beta blocker D) Cardiac glycoside

Answer: C

11) The nurse is caring for a client with hypertension. The nurse understands that the client's blood pressure is determined by all the following factors except: A) Pumping action of the heart. B) Peripheral vascular resistance. C) Heart rate. D) Blood volume.

Answer: C

The nurse is assessing a 78-year-old woman. When measuring blood pressure (BP), the nurse tells the patient that the measurement will first be taken with her in the supine position, and then she will be assisted into the sitting position and the BP will be measured again. After 3 minutes, the nurse will measure the BP one more time. What is the most likely reason that the nurse is assessing the patient's blood pressure in this way? A. Since the patient is an older adult, the BP must be taken several times and then averaged for the most accurate reading. B. The patient measures her BP at home twice daily and reports consistently high readings for the past 2 weeks. C. The patient is taking a vasodilator and should be assessed for orthostatic hypotension. D. The patient has a history of heart disease and hypertension in her family and must be assessed for hypertension.

Answer: C

The nurse is caring for a 67-year-old mother of four with a history of hypertension. Her primary care provider has recommended she begin a vasodilator medication called minoxidil. What should the nurse monitor when the patient comes in for follow-up visits? A. Serum electrolyte levels B. Liver function C. Sodium and water retention D. Unusual or masked bleeding

Answer: C A direct vasodilator such as minoxidil should cause the nurse to evaluate the patient for sodium and water retention. Serum electrolytes should be monitored closely when a patient is taking a diuretic. Liver function must be monitored when statins are used. When a patient is taking an anticoagulant, such as heparin, the nurse should monitor for masked or unusual bleeding.

A 78-year-old patient is prescribed an adrenergic antagonist, metoprolol, for hypertension. What should the nurse teach the patient about this medication? A. Pay attention for signs of muscle weakness, pain, or tenderness. B. Avoid drinking grapefruit juice while taking the medication. C. Change positions slowly to prevent potential for orthostatic hypotension. D. Check weight daily and report any rapid weight increase to the healthcare provider.

Answer: C A patient taking metoprolol should change positions slowly, because adrenergic antagonists increase the risk for orthostatic hypotension. Grapefruit should be avoided when calcium channel blockers are taken. Muscle pain, tenderness, and weakness are symptoms to monitor when a patient is taking statins. Patients taking diuretics should weigh themselves daily, because any rapid weight increase is most likely due to fluid retention. Patients should be instructed to report this to their healthcare provider.

A primary health-care provider prescribes a medication that must be administered transdermally. Which information about the route of administration does the nurse understand is related to a drug prescribed to be administered transdermally? A. Inhaled into the respiratory tract B. Dissolved under the tongue C. Absorbed through the skin D. Inserted into the rectum

Answer: C A. A medication that is aerosolized is inhaled. B. A tablet, such as nitroglycerin, is dissolved under the tongue. C. A medicated patch or disk can be applied directly to the skin, where the medication is released and absorbed over time. This method ensures a continuous therapeutic drug level and reduces fluctuations in circulating drug levels. D. Medications in the form of a suppository are inserted into the rectum.

For which clinical manifestation should the nurse monitor the client when concerned about a potential for respiratory distress? A. Productive cough B. Sore throat C. Orthopnea D. Eupnea

Answer: C A. A productive cough indicates that the person is managing respiratory secretions adequately and keeping the airway patent. B. A sore throat indicates posterior oropharyngeal irritation or inflammation. This may or may not progress to respiratory distress. C. Orthopnea, the ability to breathe easily only in an upright (standing or sitting) position, is a classic sign of respiratory distress. The upright position permits maximum thoracic expansion because the abdominal organs do not press against the diaphragm and inspiration is aided by the principle of gravity. D. Eupnea is respirations that are quiet, rhythmic, and effortless within the expected rate per minute for age.

A nurse is preparing to administer a subcutaneous injection of insulin. Which site should the nurse use to best promote its absorption? A. Upper lateral arms B. Anterior thighs C. Love handles D. Upper chest

Answer: C A. Although insulin can be administered at the deltoid site, it is a small area that is not conductive to injection rotation within the site. The rate of absorption at this site is slower than at the preferred site for insulin administration. B. Although insulin can be administered in this site, tissues of the thighs and buttocks have the slowest absorption rate. C. The areas around the waist lateral to the abdomen are the preferred sites for the administration of insulin. These areas have abundant subcutaneous tissue that has a fast rate of absorption, and they promote a systematic rotation of injections. D. The chest is not an acceptable site for the administration of insulin because of the lack of adequate subcutaneous tissue.

A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO

Answer: C A. Although meperidine is a strong analgesic, the IM route of administration can allow for slow absorption, delaying the onset of pain relief. The IM route also can cause additional pain from the injection. B. Although fentanyl is a strong analgesic, the transdermal route of administration can allow for slow absorption, delaying the onset of pain relief. C. Correct: The nurse should administer IV morphine because the onset is rapid, and absorption of the medication into the blood is immediate, which provides the optimal response for a client who is reporting pain at a level of 10. D. Although oxycodone is a strong analgesic, the oral route of administration of this medication can allow for onset of pain relief in 10 to 15 min, which can be a long time for a client who is reporting pain at a level of 10.

A client has thick, tenacious respiratory secretions. Which should the nurse do to liquefy the client's respiratory secretions? A. Change the client's position every two hours. B. Get a prescription for an antitussive agent. C. Encourage the client to drink more fluid. D. Teach effective deep breathing.

Answer: C A. Changing positions will mobilize, not liquefy, respiratory secretions. B. Mucolytics, not antitussives, liquefy respiratory secretions. Antitussives prevent or relieve coughing. C. A fluid intake of 2,500 to 3,000 mL is recommended to maintain the moisture of the respiratory mucous membranes. Adequate fluid keeps respiratory secretions thin so that they can be moved by ciliary action or be coughed up and spat out (expectorated). D. Deep breathing mobilizes, not liquefies, respiratory secretions.

A primary health-care provider prescribes chest physiotherapy with percussion and vibration for a client. After the primary health-care provider leaves, the client says, "I still don't understand the purpose of this therapy." Which statement should be included in the nurse's response? A. "It eliminates the need to cough." B. "It limits the production of bronchial mucus." C. "It helps clear the airways of excessive secretions." D. "It promotes the flow of secretions to the base of the lungs."

Answer: C A. Chest physiotherapy promotes, not eliminates, the need for coughing. B. Chest physiotherapy promotes the expectoration of, not limits the production of, bronchial mucus. C. The striking of the skin over the lung (percussion, clapping) and fine, vigorous, shaking pressure with the hands on the chest wall during exhalation (vibration) mobilize secretions so that they can be coughed up and expectorated. D. Chest physiotherapy mobilizes secretions, thus facilitating expectoration and interfering with the flow of secretions to the base of the lungs.

A client has a prescription for a vaginal cream. Which should the nurse use when placing the cream into the client's vaginal canal? A. A finger B. A gauze pad C. An applicator D. An irrigation kit

Answer: C A. Either a gloved finger or an applicator is used to insert a vaginal suppository, not a cream. B. It is impossible to insert a cream into the vaginal canal with a gauze pad. If attempted, it will traumatize the mucous membranes of the vagina. C. The consistency of a cream requires than an applicator be used to ensure the medication is deposited along the full length of the vaginal canal. D. The consistency of a cream is too thick to be inserted into the vagina with an irrigating kit.

Which is the most important action by the nurse after a client has a chest tube inserted to treat a pneumothorax? A. ensure the client's intake is at least 3,000 mL of fluid per 24 hours. B. Provide the client with adequate medication for pain relief. C. Maintain the integrity of the client's chest tube. D. Reposition the client every 2 hours.

Answer: C A. Ensuring a fluid intake of at least 3,000 mL is unnecessary. A fluid intake of approximately 2,000 mL is adequate. B. Although providing for adequate pain relief is extremely important, it is not the priority. C. A tension pneumothorax may occur if the integrity of the chest drainage system because compromised (e.g., open to atmospheric pressure, clogged drainage tube, or mechanical dysfunction). Maintaining respiratory functioning is the priority. D. Although repositioning is done to promote drainage of secretions from lung segments and aeration of lung tissue, it is not the priority.

When are effective leg exercises the nurse should encourage a client to perform to prevent circulatory complications during the postoperative period? A. Knee flexion B. Isometric exercises C. Dorsiflexion exercises D. Passive range of motion

Answer: C A. Flexing the knees exerts pressure on the veins in the popliteal space; this reduces venous return, which increases, not decreases, the risk of postoperative circulatory complications. B. Isometric exercises strengthen muscles; they do not prevent postoperative circulatory complications. Isometric exercises change the muscle tension but do not change the muscle length of move joints. C. Alternating dorsiflexion and plantar flexion (calf pumping) contracts and relaxes the calf muscles. This muscle contraction promotes venous return, preventing venous stasis that contributes to the development of postoperative thrombophlebitis. D. Passive range-of-motion exercises are done by another person moving a client's joints through their complete range of movement. This does not prevent postoperative circulatory complications because the power is supplied by a person other than the client. To facilitate circulation, a client should contract and relax muscles actively.

A nurse instructs a client to close the eyes gently after the administration of eyedrops. Which rationale for this instruction should the nurse explain to the client? A. Limits corneal irritation B. Forces excess medication from the eyes C. Disperses the medication over the eyeballs D. Prevents medication from entering the lacrimal duct

Answer: C A. Instilling medication into the conjunctival sac prevents the trauma of drops falling on the cornea. B. Closing the eyes gently, rather than squeezing the lids shut, prevents the loss of medication from the conjunctival sac. C. Closing the eyes moves the medication over the conjunctiva and the eyeball and helps ensure an even distribution of medication. D. Gentle pressure over the inner canthus for 1 minute after administration prevents medication from entering the lacrimal duct.

A home-care nurse observes the spouse of a client inserting a rectal suppository into the client. Which behavior indicates that the nurse must provide further teaching about suppository administration? A. Lubricates the tip of the suppository B. Inserts the suppository while wearing a glove C. Inserts the suppository while the client bears down D. Places the suppository a finger length into the rectum

Answer: C A. Lubrication is required to limit tissue trauma and ease insertion. B. Standard precautions should be employed when there is exposure to clients' body fluids. C. Bearing down increases intra-abdominal pressure, which impedes the insertion of the suppository. The client should be instructed to relax and breathe deeply and slowly while the suppository is inserted. D. In an adult, a suppository should be inserted 4 inches to ensure it is beyond the internal sphincter.

A client's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first? A. Notify the primary health-care provider. B. Encourage breathing deeply. C. Raise the head of the bed. D. Administer oxygen.

Answer: C A. Notifying the primary health-care provider is premature. The client's needs must be met first. B. Although encouraging deep breathing might be done eventually, it is not the priority at this time. It may or may not help. Inadequate oxygenation can be caused by a variety of problems other than shallow breathing. C. A nurse can implement this immediate, independent action. Nurses are permitted to treat human responses. Raising the head of the bed facilitates the dropping of the abdominal organs by gravity away from the diaphragm, which permits the greatest lung expansion. D. Obtaining and setting up the equipment take time that can be used for other more appropriate interventions first.

A client sucking on a hard candy inhales while laughing and develops a total airway obstruction. Which is the nurse attempting to do when implementing an abdominal thrust? A. Produce a burp. B. Pump the heart. C. Push air out of the lungs. D. Put pressure on the stomach.

Answer: C A. Producing a burp originating from the stomach in this situation is ineffective. B. Pressing on the heart (compression) is used in cardiopulmonary resuscitation (CPR). C. When trapped air behind an obstruction is forced out in response to an abdominal thrust, the forced air may push out what is causing the obstruction. D. Applying pressure against the stomach is ineffective in this situation. Whatever is causing the obstruction is not lodged in the esophagus, which leads to the stomach, but in the respiratory system.

A client is admitted with the diagnosis of lower extremity arterial disease. Which is a specific desirable outcome for a client with this diagnosis? A. Respirations within the expected range B. Oriented to the environment C. Palpable peripheral pulses D. Prolonged capillary refill

Answer: C A. Respirations within the expected range are unrelated to lower extremity arterial disease (LEAD). B. LEAD does not involve inadequate circulation to the brain. C. Palpable peripheral pulses are an appropriate expected outcome for a client with LEAD, which is a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary blood supply. A physiological response associated with LEAD is diminished or absent arterial pulses. D. A prolonged capillary refill indicates a continued problem with peripheral tissue perfusion. After compression, blanched tissue should return to its original color within 2 seconds (blanch test).

Which piece of information documented in the clinical record of a male adult should the nurse consider problematic? Client's Clinical Record Laboratory Results - WBC 8,000 cells/mcL - Hb 17 g/dL - Hct 50% Physical Assessment - BP: 132/70 mm Hg - Pulse: 100 beats per minute - Respirations: 22 breaths per minute - Temperature: 99F, oral - Oxygen saturation: 85% Medication Reconciliation Form - Levothyroxine 100 mcg, PO, daily - Simvastatin 20 mg, PO, hs - Montelukast 10 mg, PO, hs A. Simvastatin 20 mg, PO, in the evening B. Pulse 100 beats per minute C. Oxygen saturation 85% D. WBC 8,000 cells/mcL

Answer: C A. Simvastatin 20 mg once a day is within the expected dose range of 5 to 40 mg daily and is not a cause for concern. Simvastatin, a lipid-lowering agent, should be taken in the evening because the body produces the most cholesterol overnight. B. A pulse rate of 100 beats per minute is within the expected range of 60 to 100 beats per minute and is not a cause for concern. C. An oxygen saturation level of 85% is a cause for concern. An oxygen saturation level of 95% to 100% is considered expected. An oxygen saturation level of less than 90% is considered low and is associated with hypoxemia. D. A WBC count of 8,000 cells/mcL is within the expected range of 3,500 to 10,500 cells/mcL and is not a cause for concern.

A client has a prescription for an analgesic. Which nursing action is appropriate when administering this medication? A. Reassess drug effectiveness every 9 hours B. Follow the prescription exactly for the first 24 hours C. Seek a new prescription after two doses that do not achieve a tolerable level of relief D. Ask the primary health-care provider to prescribe another medication for breakthrough pain

Answer: C A. The client should be assessed every 1 to 2 hours to ensure effectiveness of the drug. B. The prescription should be followed exactly if it is a safe dose; however, if the medication is not effective, 24 hours is too long a period not to intervene. C. Two doses provide enough time to evaluate the effectiveness of a medication for pain. Clients should not have to endure intolerable levels of pain. D. Requesting additional medication is unnecessary if the drug is the appropriate dose.

Answer: C A. The intake of food or fluid with medication does not affect entry of medications into breast milk. B. The client should avoid medications that have an extended half-life due to their increased entry into breast milk. C. Correct: Taking medication immediately after breastfeeding helps minimize medication concentration in the next feeding. D. Pumping and freezing breast milk does not affect entry of medications into breast milk.

A nurse instructs a client to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The client asks, "Why do I have to hold my breath?" Which information should the nurse include in the response to the client's question? A. "It prolongs treatment." B. "It limits hyperventilation." C. "It disperses the medication." D. "It prevents bronchial spasms."

Answer: C A. There is no advantage in prolonging the treatment. B. Slow, deep breathing will limit hyperventilation. C. A pause at the height of inspiration will promote distribution and absorption of the medication before exhalation begins. D. Slow inhalations and exhalations with pursed lips help prevent bronchial spasms.

A nurse teaches a client about taking a sublingual nitroglycerin tablet. Which part of the body identified by the client indicates that the client understands the teaching? A. "On my skin." B. "Inside my cheek." C. "Under my tongue." D. "In my eye on the lower lid."

Answer: C A. Topical medications are applied on the skin. B. A troche or lozenge given by the buccal route is placed between the cheek and gums. C. A sublingual medication is placed under the tongue. It is absorbed quickly through the mucous membranes into the systemic circulation. D. A medication placed in the lower conjunctival sac of the eye is administered for its local effect and is considered a topical medication.

The instructions with a medication state to use the Z-track method of administration. Which action should the nurse implement that is specific to this procedure? Select all that apply. A. Pinch the site throughout the procedure B. Massage the site after the needle is removed C. Add 0.1 to 0.3 mL of air after drawing up the correct dosage D. Remove the needle immediately after the medication is injected E. Inject the medication quickly, at a rate of 1 second per mL of solution

Answer: C A. When the Z-track method is used during an intramuscular injection, the skin and the subcutaneous tissue are pulled laterally 1 to 1.5 inches away from the injection site, not pinched. B. Massage is contraindicated because it will force medication back up the needle track, which may result in tissue irritation or staining. C. The injection of a small amount of air after the medication is administered instills air into the Z track, and this helps to keep the medication deeply seated in the muscle. D. Removal of the needle should be delayed 10 seconds to allow the medication to begin to be dispersed and absorbed. E. The medication should be injected slowly, at a rate of 10 seconds per mL of solution. This allows time for the medication to become dispersed in the tissue, reducing back pressure on the line of needle insertion.

Which patient is likely to have the most increased blood pressure (BP)? A. A 13-month-old girl at 10:30 p.m. B. A 32-year-old African American woman at 6:30 a.m. C. A 57-year-old African American man with a BMI of 32 D. A 21-year-old woman 2 hours after a 5K run

Answer: C Factors such as age, obesity, stress, race, and sex—among other factors—have an impact on a patient's BP. For some ethnic groups (e.g., African Americans) there is a greater prevalence of hypertension. Men tend to have higher BPs than women. Older adults tend to have higher BPs than the very young or young adults. A BMI that indicates that a patient is obese also factors into BP. An older African American man who is obese according to his BMI (greater than 30) is the most likely of this group of patients to have the highest BP.

The nurse is assessing an older adult patient at home who has suctioning equipment at the bedside. The patient has a history of aspiration pneumonia. Which action is the priority? A. Requesting a prescription for a cough suppressant B. Positioning the patient on their side C. Assessing the gag reflex D. Suctioning the patient

Answer: C Given the presence of suctioning equipment and a history of aspiration pneumonia, the priority action of the nurse is to assess the patient's gag reflex. If this is poor, the nurse should position the patient in a high Fowler position, not a side-lying position. Providing a cough suppressant may put the patient at risk for aspiration as it would suppress the cough reflex. There is no indication for the nurse to suction the patient, so this would not be the priority.

The nurse is assessing a patient with a cough. Which question about the cough, if answered in the affirmative, is most concerning to the nurse? A. "Do you have clear drainage from the nose?" B. "Are you experiencing a dry cough?" C. "Do you cough up blood and how often?" D. "Do you cough up clear sputum and how often?"

Answer: C Many questions arise when asking a patient about a cough, but the nurse would determine first and foremost whether the patient is suffering from hemoptysis, or coughing up blood. This is a serious symptom and would help the nurse to determine the line of questioning to pursue. Whether the patient has clear drainage from the nose or is coughing up clear sputum are the least worrisome factors to consider. The kind of cough (dry, hacking, moist, barky, or wheezy) would give the assessment a direction but is not as important as discovering if the cough produces bloody sputum.

A patient with alterations in the respiratory system tells the nurse, "I need to stop and rest often." Which intervention should the nurse suggest? A. Teach the patient to decrease activities to preserve strength. B. Encourage the patient to increase activities to increase the ability to breath. C. Teach the patient to space activities with rest periods. D. Encourage the patient to have someone else get the patient dressed and ready to leave.

Answer: C Nurses may need to adapt schedules for patients who are hospitalized and space periods of activity with periods of rest. For patients who manage treatment at home, the nurse should teach the patient to space activities with rest periods. Encouraging the patient to increase activities to increase the ability to breath will result in increased shortness of breath. The patient should still do as much as possible to maintain appropriate physical strength and prevent deteriorating physical or mental conditions, so others should not take over all activities for the patient.

The nurse is assessing a patient with emphysema. Which symptom of emphysema is not obvious from inspection and direct observation by the nurse? A. Shortness of breath B. Barrel chest C. Hyperresonance sounds from the lungs D. Pursed-lip breathing

Answer: C Patients with emphysema and chronic obstructive pulmonary disease (COPD) would have hyperresonance sounds during an assessment using percussion. These sounds would not be obvious on inspection or observation. A patient with emphysema may be obviously short of breath, even at rest. A barrel chest is common in those with emphysema and would be obvious on inspection, even if the patient has a shirt on. Pursed-lip breathing can be observed without palpation, auscultation, or percussion.

A nurse is performing passive range-of-motion exercises for a client who is in the supine position. Which motion occurs when the nurse bends the client's ankle so that the toes are pointed toward the ceiling? A. Adduction B. Supination C. Dorsal flexion D. Plantar extension

Answer: C Rationale: A. Adduction occurs when an arm or leg moves toward or beyond the midline of the body (or both). B. Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. C. Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg. D. There is no range of motion called plantar extension. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.

A nurse is transferring a client from a bed to a wheelchair. Which should the nurse do to quickly assess this client's tolerance to this activity? A. Obtain a blood pressure. B. Monitor for bradycardia. C. Determine if the client feels dizzy. D. Allow the client time to adjust to the change in position.

Answer: C Rationale: A. Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension. B. If the client is experiencing orthostatic hypotension, the heart rate will increase, not decrease. C. Feeling dizzy is a subjective response or orthostatic hypotension. Obtaining feedback from the client provides a quick evaluation of the client's tolerance of the transfer. D. Allowing the client time to adjust to the change in position is not an assessment. This is a safe intervention for a client who is experiencing orthostatic hypotension.

An immobilized bedbound client is placed on a 2-hour turning and positioning program. Which should the nurse explain to the client is the primary reason why this program is important? A. Supports comfort B. Promotes elimination C. Maintains skin integrity D. Facilitates respiratory function

Answer: C Rationale: A. Although turning the client to a new position every 2 hours provides variety and increased comfort, these are not the primary reasons for this intervention. B. Although turning frequently promotes elimination, the upright positions, such as high-Fowler and sitting, have a greater influence on elimination because of the effect of gravity. C. Compression of soft tissue greater than 15 to 32 mm Hg interferes with capillary circulation and compromises tissue oxygenation in the compressed area. Turning the client relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences. D. Although turning and positioning promote respiratory functioning, other interventions, such as sitting, deep breathing, coughing, and incentive spirometry, have a greater influence on respiratory status.

Which word is most closely associated with nursing care strategies to maintain functional alignment when clients are bedbound? A. Endurance B. Strength C. Support D. Balance

Answer: C Rationale: A. Endurance relates to aerobic exercise that improves the body's capacity to consume oxygen for producing energy at the cellular level. B. Strength relates to isometric and isotonic exercises, which contract muscles and promote their development. C. The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bedbound clients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment. D. Balance relates to body mechanics and is achieved through a wide base of support and a lowered center of gravity.

Which is the purpose of the use of humor by a nurse when interacting with a client? A. Diminish feelings of anger B. Refocus the client's attention C. Maintain a balanced perspective D. Delay dealing with the inevitable

Answer: C Rationale: A. Humor used inappropriately can cause anger to be increased, suppressed, or repressed. Anger should be expressed safely, not diminished. B. The focus should be on the client's concerns. C. Humor is an interpersonal tool and a healing strategy. Humor releases physical and psychic energy, enhances wellbeing, reduces anxiety, increases pain tolerance, and places experiences within the context of life. D. Coping strategies should not be delayed because delay increases stress and anxiety and prolongs the process.

A client with a history of thrombophlebitis should not have pressure exerted on the popliteal space. In which position should the nurse avoid placing this client? A. Prone B. Supine C. Contour D. Trendelenburg

Answer: C Rationale: A. In the prone position, there is pressure in front of, not behind, the knees. B. In the supine position, the hips and legs are extended, which does not exert pressure on the popliteal spaces. C. In the contour position, the head of the bed and the knee gatch are slightly elevated. The elevated knee gatch pts pressure on the popliteal spaces. D. In the Trendelenburg position, the hips and knees are extended, which does not exert pressure on the popliteal spaces.

Which is being communicated when the nurse leans forward during a client interview? A. Aggression B. Anxiety C. Interest D. Privacy

Answer: C Rationale: A. Piercing eye contact, increased voice volume, challenging or confrontational conversation, invasion of personal space, and inappropriate touching convey aggression, which is a hostile, injurious, or destructive action or manner. B. A closed posture, avoidance of eye contact, increased muscle tension, and increased motor activity convey anxiety. C. Leaning forward is a nonverbal behavior that conveys involvement. It is a form of physical attending, which is being present to another. D. Privacy is not reflected by leaning forward during an interview. Privacy is facilitated by pulling a client's curtain or finding a separate room or quiet space to talk.

A nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use? A. Probing B. Clarification C. Direct questions D. Paraphrasing statements

Answer: C Rationale: A. Probing questions violate the client's privacy, may cut off communication, and are inappropriate even in a focused interview. Probing interviewing occurs when the nurse persistently attempts to obtain information even after the client indicates an unwillingness to discuss the topic or the nurse pursues information out of curiosity rather than because the information is significant. B. Although clarification may be used during a focused interview to understand what the client is saying, it is not the primary technique used for seeking specific information. C. A focused interview explores a particular topic or obtains specific information. Direct questions meet these objectives and avoid extraneous information. D. Paraphrasing may be used during a focused interview to redirect ideas back to the client so that the client can verify that the nurse received the message accurately or to allow the client to hear what was said. However, it is not a technique that obtains specific information quickly.

Which nursing action should be implemented when assisting a client to move from a bed to a wheelchair? A. Lowering the height of the bed to 2 inches below the height of the client's wheelchair B. Applying pressure under the client's axillae areas when assisting the client to stand C. Letting the client help as much as possible when transferring to the wheelchair D. Keeping the client's feet within 6 inches of each other

Answer: C Rationale: A. The bed should be higher, not lower, than the wheelchair so that gravity can facilitate the transfer. B. Applying pressure under the client's axillae areas when standing up should be avoided because it can injure local nerves and blood vessels. C. Encouraging the client to be as self-sufficient as possible ensures that the transfer is conducted as the client's pace, promotes self-esteem, and decreases the physical effort expended by the nurse. D. Keeping the client's feet within 6 inches of each other will provide a narrow base of support and is unsafe.

A nurse plans to teach a client with hemiparesis to use a cane. Which should the nurse teach the client to do? Select all that apply. A. Move forward 1 step with the weak leg first, followed by the strong leg and cane. B. Adjust the cane height 12 inches lower than the waist. C. Hold the cane in the strong hand when walking. D. Look at the feet when walking with the cane. E. Lean over onto the cane when walking.

Answer: C Rationale: A. The unaffected leg should be advanced first because the weight of the body is supported by the leg with the greatest strength. B. With the tip of the cane placed 6 inches lateral to the foot, the handle should be at the level of the client's greater trochanter to ensure that the elbow will be flexed 15 to 30 degrees when using the cane. C. A cane is a hand-gripped assistive device; therefore, the hand opposite the hemiparesis should hold the cane. Exercises can strengthen the flexor and extensor muscles of the arms and the muscles that dorsiflex the wrist. D. This action will cause flexion of the neck, hips, or waist that will move the center of gravity outside the base of support. Body alignment is essential for balance, stability, and safe ambulation. E. Leaning over onto the cane should be avoided. The client should distribute weight between the feet and the cane while standing in an upright posture. This is the most stable position when using a cane.

A client with impaired mobility is to be discharged from the hospital within a week. Which is an example of a discharge goal for this client? A. The client will understand range-of-motion exercises before they are initiated. B. The client will be taught range-of-motion exercises after they are prescribed. C. The client will transfer independently to a chair by discharge. D. The client will be kept clean and dry at all times.

Answer: C Rationale: A. This goal is not measurable as stated. Understanding is not measurable unless parameters are identified. B. This statement is a nursing intervention, not a client goal. C. This is a client-centered goal that is specific and measurable and has a time frame. D. This statement is a nursing goal, not a client goal.

A client with chest pain is being admitted to the emergency department. When asked about next of kin, the client states, "Don't bother calling my daughter; she is always too busy." Which is the best response by the nurse? A. "Your daughter might be upset if you don't call." B. "What does your daughter do that makes her so busy?" C. "Is there someone else besides your daughter that I can call?" D. "I think that your daughter would want to know that you are sick."

Answer: C Rationale: A. This may be a false assumption by the nurse. This response will put the client on the defensive and jeopardize the nurse-client relationship. B. This response requires the client to rationalize the daughter's behavior and focuses on information that is not significant at this time. C. This response lets the client know that the message has been heard and moves forward to meet the need to notify a different significant other on the client's situation. D. This provides false reassurance. Only the daughter can convey this message.

A young adult who had a leg amputated because of trauma says, "No one will ever choose to love a person with one leg." Which is the best response by the nurse? A. "You are a good-looking person, and you will have no trouble meeting someone who cares." B. "You may feel that way now, but you will feel differently as time passes." C. "Do you feel that no one will marry you because you have no leg?" D. "How do you see your situation at this point?"

Answer: C Rationale: A. This negates the client's concerns and provides false reassurance. The client needs to focus on the "negative" before focusing on the "positive." In addition, only the future will tell if the client meets someone who cares. B. This is false reassurance. There is no way the nurse can ensure that this belief will change. C. This is an example of paraphrasing, which restates the client's message in similar words. It promotes communication. D. This statement is unnecessary. The client has already stated a point of view.

A client says, "I am really nervous about having a spinal tap tomorrow." Which is the best response by the nurse? A. "I'll ask the doctor for a little medication to help you relax." B. "Clients who have had a spinal tap say it is not that uncomfortable." C. "It's all right to be nervous, and I don't remember anyone who wasn't." D. "Your physician is excellent and is very careful when spinal taps are done."

Answer: C Rationale: A. This statement avoids the client's feelings and fails to respond to the client's need to talk about concerns. It cuts off communication. B. This is a generalization that minimizes the client's concern and should be avoided. C. This statement is therapeutic. It recognizes the client's feelings, gives the client permission to feel nervous, and reassures the client that one's behavior is not unusual. This statement sets the groundwork for the next statement, such as, "Let's talk a little bit about the spinal tap and the concerns you may have." D. This is false reassurance, which discourages discussion of feelings and should be avoided.

A nurse is changing a client's dressing over an abdominal wound. Which level of space around the client is entered during the dressing change? A. Public B. Social C. Intimate D. Personal

Answer: C Rationale: A. Touching is not used with public distance. Public space (12 feet and beyond) is effective for communicating with groups or the community. Individuality is lost. B. Invasive touching does not occur with social distance. Social space (4 to 12 feet) is effective for more formal interactions or group conversations. C. Physically caring for a client involves inspection and touch that invades the instinctual, protective distance immediately surrounding an individual. Intimate space (physical contact to 1.5 feet) is characterized by body contact and visual exposure. D. "Laying on of the hands" does not occur with personal distance. Personal space (1.5 to 4 feet) is effective for communicating with another. It is close enough to imply caring and is not extended to the distance that implies lack of involvement.

When preparing to administer medication to pregnant patients, nurses should know that their patients: A. Are not at risk if they take drugs placed into pregnancy safety category X B. Can take herbal or dietary supplements without fear of teratogenic effects to their developing baby C. Are relatively safe if they take medications within pregnancy safety category B D. Should never take drugs classified as pregnancy safety category D

Answer: C Rationale: A pregnant woman may take drugs classified within pregnancy category A or B. They have been shown to be relatively safe. Drugs within all other categories have been shown to have some adverse effect on the fetus, especially category X (option 1), which has been shown to have a significant risk to both the woman and the fetus. Drugs in category D (option 4) may cause harm but can be provided if the benefit of drug outweighs the risks. All medications, including herbs or dietary substances (option 2) must be reported to the healthcare provider because some of them can have adverse effects on the fetus.

The nurse provides teaching about a drug to an older adult couple. To ensure that the instructions are understood, which of the following actions would be most appropriate for the nurse to take? A. Provide detailed written material about the drug. B. Provide labels and instructions in large print. C. Assess the clients' reading levels and have the clients "teach back" the instructions to determine understanding. D. Provide instructions only when family members are present.

Answer: C Rationale: A significant percentage of English-speaking clients do not have the basic ability to read, understand, and act on health information. This rate is even higher among non-English-speaking individuals and older clients. The nurse must be aware of the client's literacy level and take appropriate action to ensure that information is understood. Having the client "teach back" the instruction the nurse has given may ensure that it has been understood. Options 1, 2, and 4 are incorrect. Until the literacy level of the client is assessed, written materials, even in large letters, may not be appropriate for teaching. Even with low-literacy levels, it may not be necessary if the instructions given are simple and clear and the nurse confirms that the client has understood the instruction. Cognitive Level: Analyzing. Nursing Process: Evaluation. Client Need: Health Promotion and Maintenance.

Which of the following routes of drug administration has the fastest onset of action? A. Transdermal B. Intramuscular C. Intravenous D. Ophthalmic

Answer: C Rationale: Administering medication through the intravenous (IV) route provides the fastest way for medication to both reach the target tissue and begin working (onset) because the medication in injected directly into the circulatory system. Medications administered through the transdermal (option 1), intramuscular (option 2), and ophthalmic (option 4) routes allow for the onset of the medication at different rates but not faster than being directly administered into the circulatory system. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A.

Before administering drugs by the enteral route, the nurse should evaluate which of the following? A. Ability of the client to lie supine B. Compatibility of the drug with IV fluid C. Ability of the client to swallow D. Patency of the injection port

Answer: C Rationale: To prevent aspiration, the nurse should always assess to be sure that the client can swallow. Options 1, 2, and 4 are incorrect. When giving enteral medications, the client should be in an upright position to decrease the risk of aspiration. Checking the compatibility of the IV fluid and the patency of the injection port refer to IV drug administration. Cognitive Level: Applying. Nursing Process: Assessment. Client Need: Safe and Effective Care Environment.

A newly admitted client is ordered morphine 2-4 mg IV q 2 hours prn severe pain. The nurse administers 2 mg at 1000 hours for pain rated 9/10. The nurse reassesses the pain at 1020 hours and the client now rates the pain 7/10. What action by the nurse is most appropriate? A. Tell the client to wait until 1200 hours for next morphine dose B. Wait another 30 minutes to ensure the dose has peaked C. Administer 2 mg of morphine IV D. Administer 4 mg of morphine IV

Answer: C Rationale: When dealing with range doses, unless the policy specifies something different, it is safe to give the upper range dose if the lower dose range was not effective. Telling the client to wait until 1200 hours is not necessary because you only gave the lower range of the order. Because this is an IV medication, the medication is peaking around 20 minutes and therefore it is not necessary to wait another 30 minutes.

A subcutaneous injection is given at A. A 45-degree angle B. A 90-degree angle C. Either a 45- or 90-degree angle, depending on a skin fold assessment of the site D. Either a 45- or 90-degree angle, depending on the patient's body weight

Answer: C Rationale: When giving subcutaneous, the angle of my needle depends on the assessment of the site. You want to consider where the needle is ending and ensuring that the medication is going into the subcutaneous tissue and not the muscle (or dermis). If you can pinch one inch then go in at a 45-degree angle and 2 inches, 90 degrees. Perry (p. 556) points out that a ½ inch at 90 degrees can also be used however I have not seen ½ inch needle supplied at the facilities I have worked at. IM injections depend on patient's weight; however, IM injections are always given at a 90-degree angle. The needle length would be modified depending on my assessment of the client for an IM injection

The nurse is prepared to give a stat medication to a client when another client assigned codes. What action by the nurse would be most appropriate? A. Give the first client their stat medication then attend to the coding client B. Quickly drop off the medication in the room and run to the code C. Go to the code and administer the medication later

Answer: C Rationale: although stat medication is critical, priority would dictate that nurse should care for the client who is coding. The nurse may ask another nurse to give the medication, however the other nurse must prepare the meds, never administering meds another nurse prepared.

Insulin NPH 20 units is best given in (assume you have all the listed options available to you) A. An insulin syringe that can hold 100 units B. A TB syringe that can hold 1ml, with demarcations in hundredths of a ml C. An insulin syringe that can hold 30 units D. A 3ml syringe with a luer lock end, with demarcations in tenths of a ml

Answer: C Rationale: insulin must be given in an insulin syringe. Other medications should not be given in an insulin syringe and insulin should not be given in any other type of syringe, even a TB syringe. Always use the smallest syringe available.

A newly admitted client is ordered morphine 2-4 mg IV q 2 hours prn severe pain. The nurse administers 2 mg at 1000 hours for pain rated 9/10. The nurse reassessed the pain at 1030 hours and the client now rates the pain 7/10. What action by the nurse is appropriate? A. Tell the client to wait until 1200 hours for next morphine dose B. Wait another 30 minutes to ensure the medication is working C. Administer 2 mg of morphine IV D. Administer 4 mg of morphine IV

Answer: C Rationale: when dealing with range doses, unless the policy specifies something different, it is safe to give the upper range dose if the lower dose range was not effective. Telling the client to wait until 1200 hours is not necessary because you only gave the lower range of the order. Because this is an IV medication, the medication is peaking around 20 minutes and therefore it is not necessary to wait another 30 minutes.

Injection of medicine, once needle is in place, should include A. Firm pressure on the plunger to administer medicine quickly, then withdraw needle as soon as medicine is injected B. Firm pressure on the plunger to administer medicine slowly (counting to 10), then withdraw needle as soon as medicine is injected C. Firm pressure on the plunger to administer medicine slowly (counting to 10), then hold needle in place (counting to 10) before withdrawing needle

Answer: C Rationale: when giving an injection - inject the medication 1 ml over 10 seconds. You need to hold the needle in place for 10 seconds (particularly with IM injections) so that the medication distributes into the muscle.

The nurse is conducting a patient interview prior to physical assessment. The patient is a man who reports intermittent chest pain over the past several weeks. Which question should the nurse asks to elicit subjective data about the nature of the pain? A. "Have you recently gained or lost weight?" B. "Do you have a history of hypertension or heart disease in your family?" C. "Do you feel stressed or anxious about anything in particular in your life right now?" D. "Are you currently taking any medication, either prescribed or over-the-counter?"

Answer: C The interpretation of "stress" or "anxiety" may vary from person to person; asking a patient a question like this will allow for self-reporting of subjective data. Questions about medications, weight gain or loss, and/or medical history can be confirmed or verified through previous health history or physical assessment and therefore are unlikely to elicit subjective data.

A patient is experiencing decreased tissue perfusion, hypovolemia, and hypoxemia. Which action by the nurse is most important? A. Encouraging nutritional intake B. Changing a face mask to a nasal cannula C. Administering fluids D. Positioning the patient in the prone position

Answer: C The patient has decreased tissue perfusion due to hypovolemia, so fluids will increase blood volume and improve perfusion to the tissues. The prone position is not indicated for hypoxemia, because it limits lung function and expansion. Changing from a face mask to a nasal cannula will deliver less oxygen to the patient. High Fowler position can help when fluid in the lungs or decreased lung expansion is the problem.

Which independent intervention should the nurse teach the patient to prevent deep vein thrombosis (DVT)? A. Wear compression stockings when walking; when sitting still, they may be removed. B. Wear compression stockings whenever walking; when not walking, lay down, remove stockings, and elevate feet and legs above head level. C. Wear compression stockings except when bathing, showering, or sleeping. D. Wear compression stockings when sleeping, and remove upon waking.

Answer: C The patient should wear compression stockings all the time, except for bathing, showering, and sleeping. Even if the patient is sitting still during the day, compression stockings should be worn. When getting into bed, remove the compression stockings and elevate feet and legs above the heart, not head, level.

The nurse is discussing plans to care for a patient experiencing dyspnea. Which statement reflects the priority independent intervention? A. "Once a shift, I should turn the patient." B. "I should order oxygen 2 to 4 L per nasal cannula." C. "I should place the patient in high Fowler position." D. "Each morning I should weight the patient."

Answer: C The priority independent intervention for a patient who is experiencing dyspnea is to place the patient in the high Fowler position to improve oxygenation. While weighing the patient may be necessary, this is not the priority. Oxygen can only be dispensed if it is ordered by a healthcare provider. Turning the patient is an independent nursing intervention that should be done more than once a shift, but it is not a priority for this patient.

A patient asks, "Why do I need to have my position changed every 2 hours?" Which response should the nurse provide? A. "A change of position helps you clear the airway." B. "You need to be moved to prevent muscle atrophy from occurring." C. "Low oxygen in the tissues increases the risk of skin breakdown." D. "Changing positions frequently helps increase oxygen in your lungs."

Answer: C Tissue hypoxia (low oxygen levels) increases the risk of skin breakdown, which in turn increases the risk of infection and sepsis in the patient. Changing positions does not prevent muscle atrophy in a patient. Changing position does not always help clear the airway or increase oxygenation.

The nurse is assessing a patient and is preparing to measure blood pressure (BP). The nurse presents a doll and uses a stethoscope and their hands to explain how the BP will be measured. Which patient is the nurse most likely caring for based on this independent intervention? A. A 76-year old man with symptoms of hypertension B. An 18-month-old toddler whose guardians suspect may have croup C. A 6-year-old who is being seen for an annual physical D. A 32-year-old woman who is 17 weeks pregnant with her first child

Answer: C Using a doll to show a child over the age of 3 the step-by-step process of taking blood pressure is one method that a nurse can utilize to ease the anxiety or fear that the child may have. Using the doll to show adults may appear condescending or immature, and a toddler under the age of 3 is unlikely to understand the demonstration well.

A nurse obtains a client's radial pulse and notes that it is rapid and very irregular. What is the most appropriate action for the nurse to take? A. Have the client lie still for 5 minutes and attempt another measurement. B. Ask another nurse to attempt a radial pulse measurement. C. Obtain an apical pulse for 1 minute. D. Document the best estimation of the pulse.

Answer: C Rationale: An apical pulse is auscultated directly over the apex of the heart. This is truly the most accurate measurement of how many times a heart circulates blood each minute. The most frequently used site for obtaining a pulse is the radial pulse, due to the convenience of this site, but any client who has an irregular or difficult-to-obtain radial pulse should have an apical pulse taken for a full minute and documented.

A client appears anxious and nervous upon entering the healthcare provider's office. The nurse takes a blood pressure reading and notes that it is elevated. What is the next appropriate action the nurse should take? A. Instruct the client to calm down so accurate vital signs can be obtained. B. Document the blood pressure and tell the physician the client is anxious. C. Have the client rest quietly for 5 minutes and retake the blood pressure. D. Ask the client to tell you her usual blood pressure.

Answer: C Rationale: Clients may be anxious when seeking medical care in a physician's office. If a client appears anxious and the nurse obtains an elevated blood pressure reading, the nurse should promote a calm, reassuring environment and obtain the blood pressure again. A client presenting with anxiety should be assessed for underlying causes. It is important to reassure clients but also obtain accurate blood pressure readings.

Which independent nursing intervention would be most beneficial for a client who experiences extreme shortness of breath with activity? A. Elevating lower extremities to prevent edema B. Dietary teaching C. Promoting relaxation techniques D. Administering increased oxygen as needed with activity

Answer: C Rationale: Clients who have decreased perfusion and become air-hungry as they exert themselves may develop extreme anxiety. The nurse can assist with promoting relaxation and reassurance to alleviate anxiety and increase comfort. Dietary teaching should be part of teaching, but it is not a priority over managing anxiety with shortness of breath. Administering increased dosages of oxygen is a collaborative intervention that requires a healthcare prescriber's order. Elevating lower extremities can help manage edema, but it is not priority over promoting relaxation and alleviating anxiety.

Which manifestation should the nurse recognize as a sign of chronic respiratory disease in a client? A. Inspiration to expiration (I:E) ratio of 1:2 B. Crackles noted in bilateral lungs C. Clubbing of the nails D. Sudden shortness of breath

Answer: C Rationale: Clubbing of the nails can occur with chronic cardiovascular or respiratory disease. An I:E ratio (duration of inspiration to expiration ratio) of 1:2 is normal. Sudden shortness of breath and crackles can occur in acute respiratory disorders.

The nurse is teaching a client with poor peripheral perfusion about the purpose of compression stockings. Which response by the nurse would be accurate? A. "These stockings will help to keep your blood pressure elevated, especially when you stand too quickly." B. "You will notice that your skin will improve with the use of these stockings as they help protect your skin from injury." C. "These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from forming." D. "You will find that these stockings will help the heart pump more efficiently and increase the circulation to your lower extremities."

Answer: C Rationale: Compression stockings are often used by those with compromised peripheral perfusion to prevent blood from pooling in the venous system. Blood return may be slowed with poor perfusion, and blood that begins to collect in veins may form a clot. A clot that forms in leg veins may cause tissue damage and can travel up to the lungs and cause a pulmonary embolism, or it can go to the brain and cause a stroke.

A client is prescribed an oral steroid drug to improve breathing. Which instruction should the nurse provide to the client? A. "If you feel side effects, cut the dosage in half." B. "Stop the medication when your symptoms subside." C. "Be sure to follow the step-wise reduction of the medication." D. "You will probably be taking this medication long-term."

Answer: C Rationale: Exogenous steroid administration can cause suppression of natural corticosteroid production by the adrenal glands. The degree of adrenal suppression that occurs is dependent on the length of medication therapy. Because of this, discontinuation of corticosteroid medications requires a progressive, step-wise reduction (tapering) of the medication. Abrupt discontinuation can cause adrenal crisis, which is characterized by manifestations associated with insufficient glucocorticoid production, such as profound hypotension, tachycardia, and cardiovascular collapse. Because oral steroids have a number of side effects, they are usually administered for a short period of time. The client should not be told to decrease the dosage, but to call the healthcare provider if side effects occur.

The nurse is obtaining an apical pulse in an infant. What is the best site for the nurse to place the stethoscope? A. At the right nipple just above the 3rd intercostal space B. In the left mid-axillary area at the 4th intercostal space C. At the left nipple at the 4th intercostal space D. Just below the clavicle between the 1st and 2nd intercostal space

Answer: C Rationale: Heart sounds in an infant can be best auscultated around the left nipple at the 4th intercostal space. This is the loudest sound reference in infants. In adults, the sound is best heard at the apex (base) of the heart between the 4th and 5th intercostal spaces just to the left of the sternum.

A client has been diagnosed with borderline hypertension and is given a blood pressure monitor to take daily BP readings. What instructions would be appropriate for the nurse to give the client for taking home blood pressure? A. "Blood pressure readings will be erroneously high if the arm is above the level of the heart." B. "Blood pressure should be taken before getting up in the morning, with the arm elevated over the level of the heart." C. "Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated beverages." D. "Take blood pressure at different times every day to be sure it is not elevated at different times of the day."

Answer: C Rationale: The American Heart Association recommends clients who monitor blood pressure at home do so with an automatic BP cuff. Measurements should be taken with the client seated, having rested for at least 5 minutes prior, and at least 30 minutes after drinking caffeinated beverages. Blood pressure should be taken at about the same time each day, and the client should keep a log of blood pressure readings. Blood pressure readings will be erroneously low if the blood pressure is taken with the arm above the level of the heart.

Which method is the most accurate for measuring a client's respiratory rate? A. Measure the respiratory rate for 30 seconds and multiply by 2. B. Measure the respiratory rate for 6 seconds and multiply by 10. C. Measure the respiratory rate for 1 minute. D. Measure the respiratory rate for 15 seconds and multiply by 4.

Answer: C Rationale: The correct method is to count the respiratory rate for one full minute, counting one inspiration and one expiration as one breath. While the other methods may yield a 1-minute answer, they do not take into account changes in the pattern over a minute.

Which term should the nurse know describes the primary purpose of the ribs? A. Exhalation B. Inspiration C. Protection D. Deflation

Answer: C Rationale: The main job of the ribs is protecting the more fragile lungs and heart from injury during daily activity. Each set of ribs assists with respiration, but the primary purpose of ribs is to protect the lungs from puncture, bruising, and injury.

A 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse assess? A. Family History B. Age C. Stress D. Sex

Answer: C Rationale: There are numerous risk factors for development of hypertension. Certain risk factors that cannot be modified include age, sex, family history, and ethnicity. Men, African Americans, and those over 65 have an increased risk of developing hypertension, as well as those with a significant family history of heart disease. Modifiable risk factors include lifestyle choices, such as smoking, stress, sedentary lifestyle, and high-fat diet. The nurse should discuss lifestyle management with clients who are at risk for hypertension.

An older client admitted with pneumonia has a normal body temperature. What should the nurse realize as being the reason for the inconsistency in body temperature? A) The room is cold. B) The client does not have pneumonia. C) The temperature is not a valid indicator of the pathology of the illness. D) The client is losing body heat.

Answer: C Explanation: A) Older adults' temperatures may not be a valid indication of the seriousness of the pathology of a disease. Other symptoms such as confusion and restlessness may be a more accurate indicator. A decrease in temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.

Victims of a boating accident were admitted to the hospital with the diagnosis of hypothermia. What should the nurse realize as the method by which these clients lost body temperature? A) Vaporization B) Insensible water loss C) Convection D) Insensible heat loss

Answer: C Explanation: Convection is the process of heat transfer through the fluid motion of air or water across the skin. The clients of a boating accident developed hypothermia through convection. Vaporization is the continuous evaporation of moisture through the respiratory tract, mucosa of the mouth, and skin. Insensible water loss is unnoticed water loss through vaporization. Insensible heat loss is the loss of heat through vaporization.

10) A nurse working in labor and delivery understands that newborns are at great risk for alterations of thermoregulation. By drying the newborn immediately after birth, the nurse is protecting heat loss by which method? A) Convection B) Conduction C) Evaporation D) Radiation

Answer: C Explanation: Evaporation is the process of converting water to a vapor. This is the method of heat loss that occurs when a newborn baby is not dried properly. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Conduction is the process of heat transfer through physical contact of one surface to another surface. Radiation is the process of heat transfer with no physical contact.

A nurse working in labor and delivery is aware that newborns have several physiologic mechanisms that increase heat production to prevent hypothermia. What is true regarding newborn thermogenesis? A) Shivering occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system. B) Shivering thermogenesis uses the newborn's stores of brown fat to provide heat. C) Brown fat produces heat generation, and heat transfer to the peripheral circulation. D) The extra muscular activity by the infant in cold stress produces a large amount of body heat.

Answer: C Explanation: In the infant, non-shivering thermogenesis (NST) occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system. NST uses the newborn's stores of brown fat to provide heat. Brown fat produces heat generation, and heat transfer to the peripheral circulation. The extra muscular activity by the infant in cold stress does not produce body heat.

The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee. Which temperature assessment method should the nurse use? A) Axillary B) Temporal artery C) Tympanic D) Rectal

Answer: C Explanation: Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.

8) The nurse instructor is teaching a group of student nurses regarding the various layers of the heart. Which statements will the nurse include? Select all that apply. A) "The endocardium covers the entire heart and great vessels." B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat." C) "The outermost layer of the heart is the epicardium." D) "The myocardium consists of myofibril cells." E) "The myocardium has four layers."

Answer: C, D

9) A nurse working in Labor and Delivery is assessing a term newborn for congenital heart defects. The nurse understands that manifestations of an atrial septal defect (ASD) may include: A) Pulmonary artery hypotension and congestive heart failure. B) Midsystolic murmur at lower right sternal border, due to increased blood flow across the tricuspid valve. C) Mitral valve regurgitation with cleft on mitral valve. D) S1 heart tone may be split due to forceful left ventricular contraction.

Answer: C, D

A nurse is attempting to develop a helping relationship with a client who was recently diagnosed with cancer. Which factor is unique to this helping relationship? Select all that apply. A. The client should always assume the dominant role. B. The nurse and the client equally share information. C. The interaction is specific to the client. D. The interaction is guided by a purpose. E. The needs of both participants are met.

Answer: C, D Rationale: A. There are times when the nurse, not the client, must assume a dominant role; examples include when the client is unconscious, out of touch with reality, in a crisis, or experiencing panic. B. In a therapeutic relationship, the focus is on the client, not the nurse. C. The helping relationship (interpersonal relationship, therapeutic relationship) is a personal, client-focused, process. The client is the center of the health team and therefore the focus of any nurse-client interaction. D. Nursing interventions should be designed to achieve desirable client outcomes. Nursing care is purposeful and goal directed. E. The purpose of a therapeutic relationship is to focus on and meet the needs of the client, not the nurse.

To reduce the chance of duplicate medication order for the older adult returning home after surgery, what actions should the nurse take? (Select all that apply.) A. Call in all prescriptions to the client's pharmacies rather than relying on paper copies of prescriptions. B. Give all prescriptions to the client's family member. C. Take a medication history, including all OTC and prescription medications and a pharmacy history with each client visit. D. Perform a medication reconciliation before sending the client home.

Answer: C, D Rationale: With each client visit, the nurse should take a medication history of all OTC and prescription medications, noting any new medications not previously mentioned. A pharmacy history will draw attention to the possibility that the client is obtaining medications from more than one pharmacy, a potential problem in polypharmacy. Performing a medication reconciliation before the client goes home will compare the initial medication history, any new prescriptions ordered, and note any duplications, omissions, dosage changes, or questions that need to be clarified. Options 1, 2, are incorrect. Calling-in a medication does not necessarily prevent duplicate doses, especially if more than one pharmacy is used by the client. A client's family member may not know what medications the client is taking or whether additional pharmacies have been used. Cognitive Level: Analyzing. Nursing Process: Implementation. Client Need: Physiological Integrity.

5) The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client's care? Select all that apply. A) Monitor brain natriuretic peptide (BNP) level. B) Provide oxygen as prescribed. C) Assess respiratory status and lung sounds every 4 hours and as needed. D) Provide information about activity upon discharge. E) Monitor intake and output.

Answer: C, E

A primary health-care provider prescribes a liquid medication that has an unpleasant taste for a school-age child. What should the nurse do to facilitate administration of this medication? Select all that apply. A. Mix it with the child's favorite food B. Teach that the taste only lasts a short time C. Give an ice pop just before giving the medication D. Have a parent administer the medication if present E. Offer the child the choice of a spoon, needleless syringe, or dropper

Answer: C, E A. Using a favorite food or liquid to mask the taste of a medication may promote a negative association with and subsequent refusal of the favorite food or liquid. This practice should be avoided. B. Although this may be a true statement, it denies the child's dislike of the medication's unpleasant taste. C. An ice pop just before administration may numb the taste buds and minimize the unpleasant taste of the medication. D. A parent should not be asked to administer unpleasant-tasting medication, to avoid the child associating the patient with the unpleasant medication. E. Offering the child a choice supports a sense of control. Involvement in decisions limits resistance.

A client states, "I am surprised that I couldn't even eat half my breakfast." Which statement by the nurse uses the interviewing skill of reflection? Select all that apply. A. "Let's talk about your inability to eat." B. "What part of your breakfast were you able to eat?" C. "You appear startled that you did not finish your tray of food." D. "How long have you been unable to eat most of your breakfast?" E. "You seem surprised that you were unable to eat all your breakfast."

Answer: C, E Rationale: A. The nurse's response does not employ reflective technique. This open-ended statement invites the client to explore factors that may be influencing eating. B. This response is an example of a direct question, not the use of reflective technique. It elicits a minimal amount of information about only one aspect of eating. C. This statement is an example of a reflective technique because it focuses on the feeling of disbelief. D. This response is an example of a direct question (focused assessment), not the use of reflective technique. E. This statement is an example of reflective technique because it focuses on the feeling of disbelief.

A patient with impaired mobility has been prescribed axillary crutches. The nurse teaches the patient crutch walking. Which part of the body should the nurse instruct the patient to use for bearing weight when using the crutches? A. The legs B. The wrists C. The fingertips D. The axillae

B When using axillary crutches, the patient's weight should be supported by the wrists. If the axillae are used to bear the patient's weight, it could result in damage to the axillary nerve. The fingertips are too small to bear body weight. Axillary crutches are ordered to support the body when a leg is injured.

10) A nurse is educating the parents of a child born with tetralogy of Fallot. Which statement will the nurse include regarding this defect? A) "Increased pulmonary blood flow causes symptoms with this disease." B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta." C) "Your child has a decreased amount of red blood cells because of this disease." D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta." Answer: D

Answer: D

6) A client diagnosed with cardiomyopathy is being discharged to home. What client statement indicates discharge teaching has been effective? A) "I will exercise as much as possible, regardless of feeling weak and short of breath." B) "My pants getting tight around the waist, means I'm eating too much and should cut back on food." C) "I will eat foods containing sodium only if drinking water with them." D) "I will see the physician to discuss implanting a cardiac defibrillator next week."

Answer: D

7) The nurse is preparing teaching for a client with hypertrophic cardiomyopathy. For which medication classification should the nurse prepare to instruct this client? A) Digitalis B) Vasodilators C) Nitrates D) Beta blocker

Answer: D

What method would best prepare a child in kindergarten to have a blood pressure reading taken? A. Ask the parents to leave the room. B. Perform the procedure quickly, before the child notices. C. Tell the child that you're going to measure blood. D. Explain to the child that the cuff will feel tight for a few seconds, then it will loosen.

Answer: D A child in kindergarten is able to understand simple concepts and instructions. Providing a short, simple explanation and reassuring the child that the procedure will not hurt is appropriate. Parents should be allowed to remain with the child to provide reassurance. Providing partial or no explanations may increase anxiety.

A patient with respiratory difficulties lost weight over the last few months. Which action should the nurse take? A. Encourage increased activity to improve stamina in the patient. B. Begin feeding through an intravenous route. C. Obtain an order for feeding the patient through a nasogastric tube. D. Consult with dietary services to provide small, frequent meals.

Answer: D A consultation with dietary services to provide small, frequent meals would help the patient maintain or gain weight. Feeding by a nasogastric tube or intravenous route is invasive and should only be used if the patient cannot eat enough to sustain nutritional requirements. Increased activity would contribute to increased weight loss.

A nurse is administering an intradermal injection. At which angle should the nurse insert the needle? A. 90-degree angle B. 45-degree angle C. 30-degree angle D. 15-degree angle

Answer: D A. A 90-degree angle is appropriate for an intramuscular, not an intradermal, injection. B. A 45-degree angle is appropriate for a subcutaneous injection when using a needle that is 1 inch long, not for an intradermal injection. C. A 30-degree angle is too steep an angle for an intradermal injection, and a wheal will not form. D. An intradermal injection is administered by inserting a needle at a 10- to 15-degree angle through the skin with the bevel of the needle facing upward toward the skin. The small volume of medication instilled just below the epidermis causes the formation of a wheal (a localized area of swelling that appears like a small bubble).

Which action should the nurse implement to increase both the respiratory and the circulatory functions of a client in a coma? A. Encourage the client to cough. B. Massage the client's bony areas. C. Assist the client with breathing exercises. D. Change the client's position every two hours.

Answer: D A. A client in a coma is unable to respond to an instruction to cough. B. Massage increases circulation only in the localized area being massaged. In addition, massage should be performed around, not over, bony prominences. C. A client in a coma is unable to respond to an instruction to perform breathing exercises. D. Changing the client's position every 2 hours helps respirations by promoting drainage of secretions from lung segments and aerating lung tissue, which helps prevent airway obstruction and respiratory infections. Changing position helps circulation because activity increases blood flow and relieves local pressure.

Which should the nurse do first when caring for a nonverbal client who is restless, agitated, and irritable? A. Administer oxygen. B. Suction the oropharynx. C. Reduce environmental stimuli. D. Determine patency of the airway.

Answer: D A. Administering oxygen may or may not be necessary. The need for oxygen administration will depend on the results of other interventions that should be done first. B. Suctioning the oropharynx is premature. Mucus or sputum may not be the cause of the problem. C. Reducing environmental stimuli will serve no purpose at this time and is not the priority. D. Early signs of hypoxia are restlessness, agitation, and irritability resulting from reduced oxygen to brain cells. A partial or completely obstructed airway prevents the passage of gases into and out of the lungs. The ABCs (Airway, Breathing, Circulation) of emergency care identify airway as the priority.

The mother of a 5-month-old baby, who attends daycare, is concerned because the child has developed a runny nose, cough, and low-grade fever over the last few days. These symptoms are consistent with which condition? A) Meningitis B) Respiratory syncytial virus (RSV) bronchiolitis C) Bronchitis D) The common cold

B) Respiratory syncytial virus (RSV) bronchiolitis

A primary health-care provider prescribes oxygen for a client to be delivered at a high flow rate. Which additional nursing action is necessary when implementing a high-liter flow as opposed to a low-liter flow? A. Attaching a flowmeter to the wall outlet B. Providing oral hygiene whenever necessary C. Using an oil-based lubricant when caring for the nares D. Humidifying oxygen before it is delivered to the client

Answer: D A. All oxygen systems should have a flowmeter to control and maintain the flow of oxygen. B. All oxygen is drying to the oral mucosa. Therefore, oral hygiene should be provided frequently to moisten the mucous membranes. C. The use of an oil-based lubricant is unsafe because it is a volatile, flammable material in the presence of oxygen. A water-based lubricant should be used. D. A low-liter flow system administers a volume of oxygen designed to supplement the inspired room air to provide airflow equal to the person's minute ventilation (total volume of gas in liters exhaled from the lung per minute). A high-liter flow system administers a volume of oxygen designed to exceed the volume of air required for the person's minute ventilation. The low-liter flow system is less drying that the high-liter flow system, and humidification is unnecessary. A humidifier is a mechanical device that adds water vapor to air in a particle size that can carry moisture to the small airways.

Which clinical manifestation is of most concern when the nurse assesses a client who has impaired mobility? A. Shallow respirations B. Increased oxygen saturation C. Decreased chest wall expansion D. Gurgling sounds when breathing

Answer: D A. Although shallow respirations are a concern, they are not as serious as a clinical manifestation in another option. B. Oxygen saturation may be decreased, not increased, with immobility. C. Although decreased chest wall expansion is a concern, it is not as serious as a clinical manifestation in another option. D. Impaired activity contributes to accumulation of respiratory secretions in lung segments. Activity promotes drainage of secretions from lung segments and aerates lung tissue, thereby reducing the risk of airway obstruction and infection. respirations that sound gurgling (gurgles, rhonchi) indicate air passing through narrowed air passages because of secretions, swelling, or a tumor. A partial or total obstruction of the airway can occur, which is life-threatening.

An unconscious client who had oral surgery is admitted to the postanesthesia care unit. In which position should the nurse place the client? A. Prone B. Supine C. Fowler D. Lateral

Answer: D A. Although the prone position allows for drainage from the mouth, it is contraindicated because lying on the side of the face compresses oral tissues, impedes assessment, complicates oral suctioning, and may compromise the airway. B. The supine position is unsafe. In an unconscious client, the gag and swallowing reflexes may be impaired, increasing the risk for aspiration as well as letting the tongue fall to the back of the oropharynx, occluding the airway. C. The Fowler position is unsafe. An unconscious client is unable to maintain an upright position. D. The lateral position facilitates the flow of secretions out of the mouth by gravity, keeps the tongue to the side of the mouth, maintaining the airway, and permits effective assessment of the oropharynx and respiratory status.

A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding." C. "I can crush the enteric coated pill, if needed." D. "I will eat two crackers with the pain pills."

Answer: D A. Although this might help a client who has swallowing issues, it is essential for the client to swallow enteric-coated or time-release medications whole. B. Although adding a liquid medication to food is helpful if the client is having difficulty swallowing, he should not mix the medication with large amounts of food or beverages in case he cannot consume the entire quantity. C. The client must not crush enteric-coated or time-release preparations. He must swallow them whole. D. Correct: The client should take irritating medications, such as analgesics, with small amounts of food. It can help prevent nausea and vomiting.

A nurse is planning to teach one client pursed-lip breathing and another client diaphragmatic breathing. Which technique associated with diaphragmatic breathing is different from pursed-lip breathing and should be included by the nurse in the teaching plan? A. Inhale through the mouth. B. Exhale through pursed lip. C. Raise both shoulders while inhaling deeply. D. Tighten the abdominal muscles while exhaing.

Answer: D A. Inhalation is through the nose for both diaphragmatic and pursed-lip breathing. B. Exhalation through pursed lips is performed only with pursed-lip breathing. C. Raising both shoulders while breathing deeply is not part of diaphragmatic or pursed-lip breathing. The use of these accessory muscles of respiration is a compensatory mechanism that helps to increase thoracic excursion when inhaling. D. With diaphragmatic breathing, the contraction of abdominal muscles at the end of expiration helps to reduce the amount of air left in the lungs (residual volume).

Which characteristic is associated with a subcutaneous injection of 5,000 units of heparin? A. 3-mL syringe B. 22-gauge needle C. 1.5-inch needle length D. 90-degree angle of insertion

Answer: D A. Most doses of heparin are less than 1 ml. It would be difficult to withdraw an appropriate amount of heparin in a 3-mL syringe because the volume markings on the syringe are widely spaced. B. A 22-gauge needle is too large and can cause unnecessary trauma and bleeding at the insertion site. A 25- or 26-gauge needle is adequate. C. A 1.5-inch length needle is unnecessarily long and may enter a muscle rather than subcutaneous tissue. D. A 0.5-inch-length needle inserted at a 90-degree angle will ensure that the heparin is inserted into subcutaneous tissue.

A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statement should the nurse make? A. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." B. "You can safely take over-the-counter medications." C. "You should avoid any vitamin preparations containing iron." D. "Your provider can prescribe medication for nausea if you need it."

Answer: D A. Pregnancy is a contraindication for live-virus vaccines, including rubella, due to possible teratogenic effects. B. Most medications, including over-the-counter, are potentially harmful to the fetus. The client should avoid any medications unless her provider prescribes them. C. Nutritional supplements that include iron are common recommendations during pregnancy to support the health of the mother and fetus. D. Correct: Providers can prescribe medications to treat nausea and other discomforts of pregnancy.

A nurse teaches a client to make a series of short, forceful exhalations (huffing) just before actually coughing. Which information should the nurse include when explaining the purpose of this action? A. Conserves energy when coughing B. Limits pain precipitated when coughing C. Liquefies respiratory secretions when coughing D. Raises sputum to a level where it can be expectorated when coughing

Answer: D A. Regardless of the type of cough, coughing uses, not conserves, energy. However, after the airway is cleared of sputum, the client's oxygen demands will be met more effectively. B. Limiting pain precipitated by coughing is not the purpose of huff coughing. Coughing usually is not painful unless the thoracic muscles are strained or the client has had abdominal or pelvic surgery. C. An increased fluid intake, not coughing, liquefies respiratory secretions. D. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word "huff" with short, forceful exhalations keeps the glottis open and raises sputum to a level where it can be coughed up and expectorated.

Which should the nurse do to limit discomfort when administering an injection to an adult? A. Pull back on the plunger before injecting the medication B. Apply ice to the area before the injection C. Pinch the area while inserting the needle D. Inject the medication slowly

Answer: D A. Testing for a blood return prevents injecting medication directly into the circulatory system, rather than limiting the discomfort of an injection. B. Applying ice is contraindicated because it causes vasoconstriction, which limits absorption of the medication. C. Pinching the skin aids in needle insertion when administering a subcutaneous injection. It does not limit the discomfort of an injection. D. Injecting slowly allows the fluid to be dispersed gradually, which limits tissue trauma and discomfort.

A primary health-care provider prescribes a medication that must be administered via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection? A. Vastus lateralis B. Rectus femoris C. Ventrogluteal D. Dorsogluteal

Answer: D A. The vastus lateralis site is not near large nerves or blood vessels, and the muscle does not lie over a joint. It is a preferred site for infants 7 months of age and younger. B. The rectus femoris site is not near major nerves, blood vessels, or bones. It is an appropriate site for adults. C. The ventrogluteal site is not near large nerves or blood vessels. It is a preferred site in adults and children. D. The dorsogluteal site has the highest risk for injury because of the close proximity of the sciatic nerve, blood vessels, and bone.

A primary health-care provider prescribes a medicated powder to be applied to a client's lower leg. Which is most essential for the nurse to do when applying the medicated powder? A. Apply a thin layer in the direction of hair growth B. Protect the client's face with a small towel C. Dress the area with dry sterile gauze D. Ensure that the skin surface is dry

Answer: D A. This action is done with lotions, creams, or ointments. B. It is unnecessary to protect the client's face. When the powder is sprinkled gently on the site, the powder should not become aerosolized. C. A dressing is not a universal requirement. When necessary, a dressing is applied with a primary health-care provider's prescription. D. Moisture harbors microorganisms, and when mixed with a powder it will result in a pastelike substance. The site should be clean and dry to ensure effective action of the drug.

A nurse is preparing to administer digoxin to a client who states, "I don't want to take that medication. I do not want to take that medication. I do not want one more pill." Which of the following responses should the nurse make? A. "Your physician prescribed it for you, so you really should take it." B. "Well, let's just get it over quickly then." C. "Okay, I'll just give you your other medications." D. "Tell me your concerns about taking this medication."

Answer: D A. This response dismisses the client's concerns. B. The nurse is dismissing the client's concerns about taking the medication by continuing with medication administration. C. Although clients have the right to refuse a medication, the nurse should provide information about the risk of refusal instead of proceeding with medication administration. D. Correct: Although clients have the right to refuse a medication, the nurse is correct in determining the reason for refusal by asking the client his concerns. Then the nurse can provide information about the risk of refusal and facilitate an informed decision. At that point, if the client still exercises his right to refuse a medication, the nurse should notify and the provider and document the refusal and the actions the nurse took.

A home-care nurse is helping a client with short-term memory loss with how to remember to take multiple drugs throughout the day. Which should the nurse do when teaching this client? A. Suggest that the client wear a watch with an alarm. B. Ask a family member to call the client when medications are to be taken. C. Design a chart of the medications the client takes each day during the week. D. Instruct the client to put medications in a weekly organizational pill container.

Answer: D A. This suggestion is unrealistic. When the alarm goes off, the client may not remember why it is ringing. B. This suggestion is unrealistic and puts an excessive burden on family members. C. A chart is unrealistic. The chart may be complex, confusing, and require repeated cognitive decisions throughout the day that may be beyond the client's ability. D. Pill distribution can be set up once a week. After the medication is taken, the empty section reminds the client that the medication was taken, which prevents excessive doses. This is a major issue for clients with short-term memory loss.

A primary health-care provider's prescription reads, "6 L oxygen via face mask." The client, who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls off the mask. Which should the nurse do? A. Tighten the strap around the head. B. Reapply the mask every time the client pulls it off. C. Provide an explanation of why the oxygen is necessary. D. Request that the prescription for oxygen be changed to a nasal cannula.

Answer: D A. Tightening the strap around the head is unsafe because it can compress the capillaries under the strap, which may interfere with tissue perfusion and result in pressure ulcers. B. Reapplying the mask every time the client pulls it off may increase the client's agitation and it is impractical. C. Providing an explanation of why the oxygen is necessary will probably be ineffective because an agitated client often does not understand cause and effect. D. Agitated, confused clients generally tolerate a nasal cannula better than a face mask. A nasal cannula (nasal prongs) is less intrusive than a mask. Masks are oppressive and may cause a client to feel claustrophobic.

A 70-year-old patient states that they exercise daily and notice that they now must rest for longer periods between activities. How should the nurse respond? A. "Your blood pressure drops when you stop the activity. As a result, it takes longer for your blood pressure to rise than it did when you were younger. Therefore, you need longer rest periods between activities." B. "The amount of blood you pump through your heart during exercise is greater than when you are at rest. This amount increases as you get older, requiring you to rest more between activities." C. "Your pulse rate increases during activities. As you get older, this increase lessens, causing you to become more tired during activities. This requires that you rest for longer periods of time between activities." D. "Your heart rate increases with the activities, but it takes longer to return to your normal rate than it did when you were younger. This results in your needing longer rest periods between activities."

Answer: D Age-related cardiac changes include decreased contractility of the myocardium as well as an increase in the thickness of the shell surrounding the sinoatrial (SA) node and a decrease in the number of pacemaker cells. This causes decreased cardiac output (CO) when under physiologic stress, such as exercise, resulting in tachycardia that lasts longer than in younger people. The individual may therefore require rest time between activities. Blood pressure increases, not decreases, to compensate for increased peripheral resistance and decreased CO in the older adult.

A 70-year-old patient states that they exercise daily and notice that they now must rest for longer periods between activities. Which factor is most likely causing this response? A. Decreased pulse to compensate for change in stroke volume B. Decreased stroke volume related to exercise C. Lower blood pressure due to decreased cardiac output D. Decreased cardiac output resulting in longer period of tachycardia

A patient who takes an inhaled corticosteroid reports dizziness and heart palpitations and has a heart rate of 110 beats/min and a blood pressure of 88/44 mmHg. Which question should the nurse ask first? A. "Are you having any difficulty with urination?" B. "Did you use your albuterol inhaler today?" C. "Does your mouth feel dry?" D. "When did you last take your inhaled corticosteroid?"

Answer: D Asking about the time of the last inhaled corticosteroid taken is appropriate because abrupt discontinuation can cause adrenal crisis, which is characterized by manifestations associated with insufficient glucocorticoid production, such as profound hypotension, tachycardia, and cardiovascular collapse. Use of an albuterol inhaler could account for tachycardia, but not the blood pressure. Difficulty with urination and dry mouth might occur with an anticholinergic medication.

A patient has increased shortness of breath and mucous plugs in the lungs. Which test should the nurse expect to be performed? A. Pulmonary function test (PFT) B. Arterial blood gases (ABGs) C. Thoracentesis D. Bronchoscopy

Answer: D Bronchoscopy is an invasive procedure that can be used to remove mucous plugs from the lungs. Thoracentesis is used to remove fluid from the pleural space. PFT is used to measure changes in lung function but is not used to treat mucous plugs. ABGs test for acid-base imbalance, but they are not treatment for mucous plugs.

The nurse taught a patient with alterations in the respiratory system about lifestyle alterations. Which patient statement indicates an understanding of the teaching? A. "I should have someone get me dressed when I am short of breath." B. "I will need to decrease my activities to preserve my strength." C. "I should take up some aerobic exercise in order to increase my ability to breathe." D. "I should space activities with plenty of rest periods when I am short of breath."

Answer: D For patients who manage treatment at home, the nurse should teach the patient to space activities with rest periods. Aerobic activities will result in increased shortness of breath. The patient should still do as much as possible to maintain appropriate physical strength and prevent deteriorating physical or mental conditions, so others should not take over all activities for the patient.

The nurse is providing teaching to a 60-year-old patient with heart failure. Which is the most important concept related to dietary management the nurse should include? A. Increase calcium intake. B. Increase fluid intake. C. Decrease fat intake. D. Reduce sodium intake.

Answer: D It is important for patients with heart failure and impaired perfusion to decrease sodium intake. Sodium leads to the retention of fluid, specifically in the cardiopulmonary system, depressing breathing efforts and heart function. Decreasing sodium will prevent edema and retention of fluid, thus improving perfusion. While decreasing fat intake is important, it does not pose as an immediate threat to health as fluid intake.

The nurse is evaluating teaching provided to a patient with newly diagnosed hypertension. Which patient statement indicates that the teaching has been effective? A. "Half of the people with high blood pressure die within 5 years of diagnosis." B. "High blood pressure is the leading cause of disability in the United States." C. "High blood pressure is the leading cause of death in the United States." D. "Uncontrolled high blood pressure can cause a heart attack or a stroke."

Answer: D Nurses can provide teaching to patients at a primary level to reduce the risk of cardiac disease later in life. In this situation, the nurse provides information to the patient about the impact of uncontrolled high blood pressure later in life. High blood pressure affects 31% of American adults and can lead to a heart attack and stroke. Heart disease is the leading cause of death in the United States. Stroke is the leading cause of disability in the United States. Half of the people with heart failure will die within 5 years of diagnosis.

A nurse identifies the seven components of wellness as a useful tool in assessing health. Which are some of the components of wellness? Select all that apply. A. Financial B. Physical C. Emotional D. Spiritual E. Environmental

BCDE

A nurse is a community center is conversing with a group of older adults who voiced fears about falling. Which is the most common consequence associated with older adults' fear of falling that the nurse should discuss with them? A. Impaired skin integrity B. Occurrence of panic attacks C. Self-imposed social isolation D. Decreased physical conditioning

Answer: D Rationale: A. A person who chooses not to ambulate still has the ability to assume many different sitting or lying-down positions. B. The occurrence of panic attacks is not the most common consequence. Anxiety and ultimately panic that is precipitated by a situation can be prevented by avoiding the situation. C. A person who chooses not to ambulate because of a fear of falling still can socialize. D. Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5% to 10% per week, so that within 2 months of immobility more than 50% of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These responses result in decreased physical conditioning.

Which statement about communication should the nurse consider to be accurate? A. Verbal communication is essential for human relationships. B. Hands are the most expressive part of the body. C. Behavior clearly reflects feelings. D. Communication is inevitable.

Answer: D Rationale: A. All communication, not just verbal communication, is essential for human relationships. B. The face, not the hands, is the most expressive part of the body. C. Behavior may imply, not clearly reflect, feelings. The nurse should obtain verbal feedback from the client regarding assumptions about behavior. D. Theory indicates that all behavior has meaning, people are always behaving, and we cannot stop behaving or communicating; therefore, communication is inevitable.

Which nursing action is most effective in relation to the concept Immobility can lead to occlusion of blood vessels in areas where bony prominences rest on a mattress? A. Encouraging the client to breathe deeply 10 times per hour B. Performing range-of-motion exercises twice a day C. Placing a sheepish pad under the sacrum D. Repositioning the client every 2 hours

Answer: D Rationale: A. Deep breathing prevents atelectasis and hypostatic pneumonia, not pressure ulcers, which this question is about. B. Range-of-motion exercises help prevent contractures, not pressure ulcers. C. Although sheepskin reduces friction and limits pressure, its main purpose is to allow air to circulate under the client to minimize moisture and maceration of skin. D. Turning a client relives pressure on the capillary beds of the dependent areas of the body, particularly the skin overlying bony prominences, which reestablishes blood flow to the area. When pressure on a capillary exceeds 15 to 32 mm Hg, its lumen is occluded, depriving oxygen from local body cells.

A client is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the primary health-care provider will prescribe for this client? A. Heat lamp treatment three times a day B. Application of a topic antibiotic C. Cleansing irrigations twice daily D. Debridement of the wound

Answer: D Rationale: A. Heat lamp treatments will further dry out the wound and can cause burns. B. Topical antibiotics are used only when the ulcer is infected, not to treat eschar. C. Cleansing irrigations are ineffective in removing the thick, fibrin-containing cells of eschar covering the surface of the wound. D. Thick, leatherlike, necrotic, devitalized tissue (eschar) must be removed surgically or enzymatically before wound healing can occur.

Which do nurses sometimes do that increases their risk for injury when moving clients? A. Use longer, rather than shorter, muscles when moving clients B. Place their feet wide apart when transferring clients C. Pull rather than push when turning clients D. Rotate their backs when moving clients

Answer: D Rationale: A. Nurses should use the longer, stronger muscles of the thighs and buttocks when moving clients to protect their weaker back and arm muscles. B. Nurses should have a wide base of support when moving clients to provide better stability. C. Nurses should use a pulling motion to turn clients because the muscles that flex, rather than extend, the arm are stronger, and pulling, rather than pushing, creates less friction and therefore less effort. D. Twisting (rotation) of the thoracolumbar spine and flexion of the back place the line of gravity outside the base of support, which can cause muscle strain and disabling injuries. Misaligning the back when moving clients occurs most often when not facing the direction of the move.

A client states, "Do you think I could have cancer?" The nurse responds, "What did the doctor tell you?" Which interviewing approach did the nurse use? A. Paraphrasing B. Confrontation C. Reflective technique D. Open-ended question

Answer: D Rationale: A. The nurse's response is not an example of paraphrasing, which is restating the client's basic message in similar words. B. The nurse's response is not an example of confrontation. A confronting or challenging statement fails to consider feelings, puts the client on the defensive, and is a barrier to communication. C. The nurse's response is not an example of reflective technique, which is referring back the basic feelings underlying the client's statement. D. This open-ended statement invites the client to elaborate on the expressed thought with more than a one- or two-word response.

Which stage pressure ulcer requires the nurse to measure the extent of undermining? A. Stage 0 B. Stage I C. Stage II D. Stage III

Answer: D Rationale: A. There is no stage 0 in the classification system for staging pressure ulcers. B. The skin is still intact and there is no undermining in a stage I pressure ulcer. C. Tissue damage is superficial and there is no undermining in a stage II pressure ulcer. D. In a stage III pressure ulcer, there is full-thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia, and there may or may not be undermining, which is tissue destruction underneath intact skin along wound margins.

A client states, "I think that I am dying." The nurse responds, "You believe that you are dying?" Which interviewing approach did the nurse use? A. Focusing B. Reflecting C. Validating D. Paraphrasing

Answer: D Rationale: A. This is not an example of focusing, which centers on the key elements of the client's message in an attempt to eliminate vagueness. It keeps a rambling conversation on target to explore the major concern. The client was not rambling. B. This is not an example of reflecting, which focuses on feelings. C. This is not an example of validating. Consensual validation, a form of clarification, verifies the meaning of specific words rather than the overall meaning of the message. This ensures that both client and nurse agree on the meaning of the words used. D. The nurse's response is an example of paraphrasing because it uses similar words to restate the client's message.

A client is exhibiting anxious behavior and states, "I just found out that I have cancer everywhere, and I don't have very long to live. My life is over." Which is the best response by the nurse? A. "It might be good if your family were here right now. Shall I call them?" B. "What might be the best way to approach this terrible news?" C. "That is so sad. You must feel like crying." D. "It sounds like you feel hopeless."

Answer: D Rationale: A. This response abdicates the nurse's responsibility to explore the client's concerns immediately. In addition, it could be an erroneous assumption. B. The client is in the shock and disbelief mode of coping and will not be able to explore approaches to coping. In addition, using the words "terrible news" may increase anxiety and hopelessness. C. This response imposes the nurse's feelings and own coping skills into the situation. D. This is an example of reflective technique because the nurse incorporated the client's feelings into the response. When no solutions to a problem are evident, a person becomes hopeless (i.e., despairing, despondent).

A client is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Which is the nurse's best response? A. "It's natural to worry about your job." B. "Your job must be very important to you." C. "Calm down so that I can understand what you are saying>" D. "I'm not quite sure I heard what you were saying about your work."

Answer: D Rationale: A. This response may or may not be an accurate assumption. B. This response makes an assumption that may be erroneous. C. This patronizing response treats the client is a condescending manner. The client cannot calm down. D. This response requests additional information in an attempt to clarify an unclear message.

A nurse is caring for a client who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with this client? A. Touch the client's left arm before initiating a conversation. B. Ensure that the door to the client's room is on the client's left side. C. Close the window curtains and dim the lights before speaking with the client. D. Knock on the door and request permission to enter before approaching the client.

Answer: D Rationale: A. Touching a client with a visual impairment before speaking is an intrusive action and may startle the client. B. A door to the room on the client's left side will require the client to completely turn the head to the left so that the client can use the right eye to view a person entering the room. The door should be on the client's right side. C. Clients with visual impairments may still have some sight. Adequate lighting facilitates nonverbal communication. D. Knocking on the door before entering the room alerts the client that someone is at the door, and requesting permission to enter the room demonstrates respect and provides for privacy.

Injection sites, in order according to absorption, are (select answer with fastest absorption first, slowest last) A. Intradermal, subcutaneous, intramuscular B. Intradermal, intramuscular, subcutaneous C. Subcutaneous, intramuscular, intradermal D. Intramuscular, subcutaneous, intradermal

Answer: D Rationale: Because the muscle is highly vascular, this med will absorb the fastest.

A client is going to surgery. Which medications should be given? A. All po and IV medications due B. None of the medications C. Only IV medications D. IV medications and po pre-operative medications

Answer: D Rationale: The client is NPO so most medication given parenterally can be given (however know the action of the drug). If ordered, preoperative medications can be given with sips of water (no more than 30 mL's of water).

Which of the following statements is correct? A. Because chemical drug names are often complicated and difficult to remember or pronounce, the chemical structure of a drug is rarely considered in pharmacotherapy. B. Matching one active ingredient with one trade name product is not a particularly challenging job for the healthcare provider. C. When referring to a drug, the generic name is usually capitalized, whereas the trade name is written in lowercase. D. The drug trade name is sometimes called the proprietary name, suggesting ownership.

Answer: D Rationale: The inert ingredients in a brand name and its generic form can differ. This difference can affect bioavailability, therefore affecting the drug's reaction in the body. Drug formulations for brand name drugs are not always the same as their generic equivalents (option a). In fact, ingredients may be more tightly compressed either in brand name drugs or in generic drugs, making option b incorrect. Option c, generic drugs are not always best for treatment, despite their lower costs.

An older adult client tells the nurse that she has been using several herbal products recommended by a friend. Why would the nurse be concerned with this statement, given the age of the client? A. The older adult client may have difficulty reading labels and opening bottles and confuse medications. B. The older adult client may have difficulty paying for additional medications and stop using prescribed drugs. C. The older adult client may be more prone to allergic reactions from herbal products. D. The older adult client may have other disease conditions that could increase the risk for a drug reaction.

Answer: D Rationale: The older adult client is more likely to have chronic ailments such as renal, cardiac, or hepatic disease that could increase the risk for a drug-herb interaction. Options 1, 2, and 3 are incorrect. Not all older adult clients have difficulty with reading labels, opening bottles, or financial concerns that would affect the ability to obtain prescribed medication. When these situations occur, the nurse should assess the impact they have on the client's ability to safely take medication. Older adults are not more prone to develop allergies from an herbal product and may be less sensitive to allergens, due to a declining immune system. Cognitive Level: Applying. Nursing Process: Assessment. Client Need: Physiological Integrity.

A client with diabetes has been NPO since midnight for surgery in the morning. He usually takes an oral type 2 antidiabetic drug to control his diabetes. What would be the best action for the nurse to take concerning the administration of his medication? A. Hold all medications as ordered. B. Give him the medication with a sip of water. C. Give him half the original dose. D. Contact the provider for further orders.

Answer: D Rationale: While a client who is NPO for surgery is not usually allowed anything to eat or drink, crucial medications, such as drugs to control blood glucose levels, may be allowed or a different form (e.g., insulin by injection) may be given. The nurse should contact the provider and check whether any additional orders are needed. Options 1, 2, and 3 are incorrect. The nurse should ensure that the provider is aware of the client's need for the medication and whether the client can take the drug with sips of water. It is not within a nurse's scope of practice to determine the amount of dosage a client takes without an order. Cognitive Level: Analyzing. Nursing Process: Implementation. Client Need: Safe and Effective Care Environment.

The nurse is assessing a middle-aged woman during an annual physical who casually mentions that she experiences shortness of breath and chest pain, usually together, but never for extended periods of time. Which question from the nurse has the patient most likely answered "Yes" to, causing the nurse to look further into her report of shortness of breath and pain? A. "Have you had your cholesterol checked recently?" B. "Do you sleep well at night and feel rested in the morning when you wake?" C. "Has anyone in your family had cancer?" D. "Do you smoke cigarettes or cigars, chew tobacco, or use an e-cigarette?"

Answer: D Using any form of tobacco or nicotine can increase the risk for hypertension and heart disease. If the patient confirms that they smoke cigarettes and also reports occasional shortness of breath or chest pain, the nurse is likely to continue to ask further questions related to heart health and perfusion. A family history of cancer, self-report of good sleep habits, and having one's cholesterol recently checked are not necessarily risk factors for heart disease or hypertension.

A nurse is performing an assessment on a 65-year-old client. Which subjective assessment finding could indicate a decrease in perfusion? A. Decreased appetite B. Nocturnal leg cramping C. Reporting the need for a mid-afternoon nap D. Sleeping with more pillows or in a recliner

Answer: D Rationale: A person who develops decreased perfusion over time may require more pillows at night in order to sleep in an upright position, which could make breathing easier. A client who reports needing additional pillows or feeling short of breath at night should have further evaluation. Decreased appetite could be related to illness or medication, and needing a mid-afternoon nap may be an effect of aging. Nocturnal leg cramps are usually sudden spasms of muscles in the calf, which may be due to exercise, electrolyte imbalance, dehydration, medication, pregnancy, or other medical conditions.

A client is prescribed medication for an elevated body temperature. What would be appropriate for the nurse to provide to the client? A) Muscle relaxant B) Antihypertensive C) Sedative D) Antipyretic

Answer: D Explanation: Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Muscle relaxants and sedatives do not reduce body temperature.

During an assessment, a client who was a victim of an industrial accident has a mildly elevated body temperature. To what should the nurse attribute the client's increase in body temperature? A) Infection B) Diet C) Exercise D) Stress

Answer: D Explanation: Factors that affect body temperature include age, diurnal variations, exercise, hormones, stress, and environment. The client who is a victim of an industrial accident most likely has a temperature elevation because of stress. There is no evidence presented to suspect infection. The client was not exercising. Diet does not influence body temperature.

Which route is associated with the administration of a suppository? Select all that apply. A. Ear B. Nose C. Mouth D. Vagina E. Rectum

Answer: D, E A. Medicated solutions are administered via drops in the ear. B. Medicated solutions are dropped or sprayed in the nose. C. Tablets, lozenges, and troches are administered in the mouth. D. Semisolid cone-shaped or oval suppositories that melt at body temperature can be inserted into the vagina. E. Semisolid cone-shaped or oval suppositories that melt at body temperature are inserted rectally.

A nurse is placing a client in the left-lateral position. Which of the following should the nurse implement when positioning this client? Select all that apply. A. Maintain the left knee flexed at ninety degrees. B. Rest the right leg on top of the left leg. C. Place the ankles in plantar flexion. D. Align the shoulders with the hips. E. Protract the left shoulder.

Answer: D, E Rationale: A. This excessive flexion can result in contractures of the hip and knee. The left leg should be slightly flexed or extended. B. The right leg should be supported on a pillow in front of the left leg. C. The ankles should be maintained at 90 degrees. D. Maintaining alignment of the shoulders and hips avoids stress and strain on the bones, muscles, and joints. E. In the left-lateral (side-lying) position, the left arm is positioned in front of the body with the shoulder pulled forward (protracted). This position reduces pressure on the joint in the shoulder and acromial process.

6) The nurse is caring for a client admitted with minor burns and elevated body temperature after being in a house fire. What should be included in this client's plan of care? Select all that apply. A) Providing blankets B) Keeping the room temperature warm C) Restricting fluids D) Encouraging fluids E) Lowering room temperature

Answer: D, E Explanation: The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.

The OR just called and is coming to pick the patient up for surgery. You now need to start the antibiotic that is due (order for Cipro OCTOR). The provider just put in a stat order for Metoprolol IV for increased BP and the patient rings the call bell asking for pain medication. Which order would you implement first, second, third and why?

Answer: I would first administer a stat dose first because stat orders take precedence over other orders. Next I would start the antibiotic because this is time sensitive, finally, I would administer the pain medication. Although pain is very important, as a nurse I must give priority to the above order types first.

True/false: it is important to assess the patient's response to a medication, especially if it is the first dose.

Answer: True Rationale: As nurses we always evaluate the effectiveness of our intervention and medication is an intervention.

TRUE or FALSE - Needle length is selected depending on client assessment

Answer: True Rationale: Needle length does depend on the client assessment. Usually subcutaneous injections are given with a 5/8 needle but can be given with a ½ inch (at 90 degrees). Needle length for IM injections depends on weight, which is a part of the client assessment.

A patient is suspected of having a spinal cord injury. The nurse tells the patient, "Your healthcare provider has ordered a diagnostic test that measures how your nerves respond to stimulation." The nurse is referring to which test? A. Spinal x-rays B. Magnetic evoked potentials C. MRI of the spine D. CT of the spine

B Magnetic evoked potentials can be used to detect neural response to physiological, electrical, or magnetic stimulation. Common sites for stimulation include the median nerve, the common peroneal nerve, and the posterior tibial nerve. Spinal x-rays identify fractured vertebrae; they do not measure nerve conduction. MRIs and CTs are used to determine the level of the spinal cord that is damaged, not to measure neural response.

A client with eroding cartilage of the left knee asks the nurse why bruising is absent because bruising was present when they injured their knee a few months ago. Which response by the nurse is accurate? A. "Cartilage is eroded because blood vessels are harmed." B. "Cartilage does not contain blood vessels." C. "This injury damaged the blood vessels." D. "The cartilage has eroded all blood vessels."

B Rationale: Ligaments and tendons contain blood vessels, but cartilage does not. Because of this, bruising will be absent with cartilage erosion. The previous injury caused a bruise because either ligaments or tendons were injured. Cartilage erosion does not damage blood vessels. Cartilage does not erode blood vessels. Cartilage does not erode because blood vessels are harmed.

7) A client with a body temperature of 104°F is entering the flush phase of the fever. What should the nurse do to assist this client? Select all that apply. A) Restrict fluids. B) Cover the client with a light sheet. C) Monitor intake and output. D) Cover the client with warm blankets. E) Provide warmed intravenous fluids

B C During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to increase the body's heat loss. Covering the client with a light sheet is the intervention to use at this time. The nurse should also monitor the client's intake and output. Warm blankets and warm intravenous fluids will increase the body's temperature. Restricting fluids could lead to dehydration and a higher body temperature.

5) A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic test(s) will the nurse expect the client to have performed? Select all that apply. A) CT scan of the abdomen B) Chest x-ray C) Urinalysis D) Complete blood count E) Bone scan

B C D The diagnostic tests will focus on trying to find the cause of the elevated body temperature. The complete blood count will be done to see if there is an elevation in white blood cells. The urinalysis will be done to see if the client has a urinary tract infection. The chest x-ray will be done to see if the client has a lung infection. A bone scan and CT scan of the abdomen may or may not be indicated for this client.

5) The nurse is planning to instruct a new mother on ways to prevent hypothermia in her newborn. What should this teaching include? Select all that apply. A) Expect the baby to shiver. B) Keep the newborn's head covered. C) Cover the newborn with a light sheet during afternoon naps. D) Notice changes in the baby's respirations and take the appropriate action. E) Cover the newborn with minimal blankets when out of doors in temperatures in the 50s

B D Chilling can cause signs of respiratory distress in the newborn. The nurse should instruct the mother to be aware of changes in respirations, which would indicated that the baby is cold and needs to be protected. Covering the newborn's head will also reduce heat loss. The newborn should be covered with more than a light sheet during afternoon naps. The newborn should be protected with many blankets when out of doors in temperatures in the 50s. Shivering is not expected and means that the baby's metabolic rate has doubled.

2) A young adult client is brought into the Emergency Department with hypothermia. Which factor(s) does the nurse identify as contributing to this client's condition? Select all that apply. A) Wearing light socks and tennis shoes B) Alcohol intake C) Walking outdoors in 30°F weather D) Not wearing a hat E) Standing outdoors during a snow storm without a coat

B E Alcohol causes peripheral vasodilation, which exposes the circulating bloodstream to more rapid cooling, resulting in a faster decrease in body temperature. The client's intake of alcohol contributed to the development of hypothermia. Standing outdoors during a snow storm without a coat also could have contributed to hypothermia. Skin freezes when the temperature drops to 14-24.8°F. Not wearing a hat and wearing light socks and tennis shoes may not have helped but did not cause the client to develop hypothermia.

5) A client has been receiving care for an elevated body temperature. Which assessment finding or findings indicate that care has been effective? Select all that apply. A) Urine output of 20 ml/hour B) Moist mucous membranes C) Heart rate of 120 beats per minute D) Good skin turgor E) Blood pressure of 118/68 mmHg

B D Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 ml/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.

The nurse is evaluating care provided to a new mother whose infant is at risk for sudden infant death syndrome (SIDS). Which statement by the mother indicates teaching has been effective? A) "I need to purchase loose-fitting sheets and blankets for the bed." B) "I plan to quit smoking." C) "I will place my baby in a side-lying position for sleep." D) "I will bottle-feed my baby since breastfeeding is a risk factor for SIDS."

B) "I plan to quit smoking."

The nurse instructs a client with asthma on bronchodilator therapy. Which statement indicates client understanding of how the drug works? A) "The medication widens the airways by causing airway muscle contraction." B) "The medication widens the airways by causing airway muscle relaxation." C) "The medication widens the airways by decreasing histamine production." D) "The medication widens the airways by decreasing mucus production."

B) "The medication widens the airways by causing airway muscle relaxation."

A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the parents indicates effective teaching? A) "We'll be sure to use the fireplace often to keep the house warm in the winter." B) "We will replace the carpet in our child's bedroom with tile." C) "We'll keep the plants in our child's room dusted." D) "We're glad the dog can continue to sleep in our child's room."

B) "We will replace the carpet in our child's bedroom with tile."

Several nurses are discussing the Joint Commission's 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients correctly? A) Labeling all medications with the client's name B) Consistently using two methods to identify the client C) Asking the client's name before conducting assessments D) Marking the intended surgical site on the client

B) Consistently using two methods to identify the client Two elements of performance that accompany the goal to identify clients correctly include consistently using two methods to identify the client and ensuring that clients receiving blood transfusions are correctly identified prior to transfusion. Labeling medications with the medication information helps prevent medication errors, and marking the intended surgical site on the client helps prevent surgical errors. Asking the client's name before conducting assessments is not associated with a National Patient Safety Goal

The nurse is developing a plan of care for a toddler diagnosed with respiratory syncytial virus (RSV). Which intervention is inappropriate for this client? A) Offer small, frequent meals. B) Encourage to ambulate frequently. C) Encourage oral intake. D) Monitor intake and output.

B) Encourage to ambulate frequently.

The nurse is providing care to a client with ARDS who has a tracheostomy. The nurse will monitor the client for complications related to the loss of which protective mechanism? A) The ability to cough B) Filtration and humidification of inspired air C) Decrease in oxygen-carrying capacity of the trachea D) The sneeze reflex initiated by irritants in the nasal passages

B) Filtration and humidification of inspired air

Besides the respiratory system, which system would be critical for the nurse to assess in a client recently diagnosed with cystic fibrosis? A) Nervous system B) Gastrointestinal system C) Musculoskeletal system D) Urinary system

B) Gastrointestinal system

The nurse is providing teaching to the client who is pregnant and has cystic fibrosis. The nurse should explain that the client is at increased risk for which condition? A) Emergency delivery B) Gestational diabetes C) Placenta previa D) Spontaneous abortion

B) Gestational diabetes

The nurse is caring for a 72-year-old client who has presented to the emergency department for the third time in 8 months with acute asthma exacerbations. The client states that he has trouble holding his inhaler, and sometimes he forgets to take his medication. He is also worried because he thinks his new drugs are adversely interacting with medications for his other conditions. What nursing diagnosis is appropriate for this client? A) Deficient Knowledge B) Ineffective Health Management C) Risk for Aspiration D) Ineffective Coping

B) Ineffective Health Management

The nurse is providing parenting teaching regarding reducing the risk of sudden infant death syndrome (SIDS). Which teaching point is a priority for the nurse to include? A) Instruct on side-lying and face-down positions when in the crib. B) Instruct on face-up position when in the crib. C) Ensure adequate nutritional intake for the mother and newborn. D) Encourage good hand washing.

B) Instruct on face-up position when in the crib.

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygenation? A) Oxygen via a nasal cannula B) Mechanical ventilation C) Oxygen via a face mask D) Oxygen via a Venturi mask

B) Mechanical ventilation

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should the nurse include in the child's plan of care to address the nursing diagnosis Impaired Gas Exchange? Select all that apply. A) Weigh daily. B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed. D) Weigh diapers. E) Provide frequent rest periods.

B) Monitor vital signs and pulse oximetry. C) Administer oxygen as prescribed.

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client? A) Face mask B) Nasal cannula C) Nonrebreather mask D) Venturi mask

B) Nasal cannula

B) Nasal cannula The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

After completing an assessment, the nurse determines a client is at risk for safety issues. Which data supports the nurse's conclusion? A) Lives with adult married daughter and family B) Occasional dizziness with walking C) Follows a vegetarian diet D) Receives an annual ophthalmologic examination

B) Occasional dizziness with walking Risks to safety include factors that can impact falls such as mobility issues or balance. Living with family, eating a vegetarian diet, and having annual eye examinations do not increase the client's risk for safety issues.

Which data supports the nurse's assessment that a newborn with acute respiratory distress syndrome (ARDS) is improving? A) Increased PaCO2 B) Oxygen saturation of 92% C) Pulmonary vascular resistance increases D) Thick secretions from the respiratory tract

B) Oxygen saturation of 92%

The nurse is caring for an 18-month-old client who is newly diagnosed with cystic fibrosis. The client is currently hospitalized due to a Pseudomonas aeruginosa infection in the lungs. The client's vital signs are: P 138, R 43, T 101.3°F, BP 86/40, SpO2 88%. The client is coughing up thick, green mucus. What independent nursing intervention can the nurse implement to improve the client's oxygenation? A) Administration of CFTR modulators B) Percussion and postural drainage C) Nutritional counseling D) Teaching the client to cough into a tissue

B) Percussion and postural drainage

A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support. Which nursing actions are appropriate for this client? Select all that apply. A) Increase percentage of oxygen being provided through the ventilator. B) Place in the Fowler position. C) Provide morning care during the weaning procedures. D) Begin weaning procedures in the morning. E) Medicate with morphine for pain as needed.

B) Place in the Fowler position. D) Begin weaning procedures in the morning.

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention? A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler. B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment. C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds. D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.

B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.

One primary method for preventing ARDS in hospitalized clients is A) performing postural drainage for clients with respiratory congestion. B) elevating the head of the bed for clients who are ingesting food. C) providing smoking cessation literature to clients who smoke. D) administering oxygen as ordered by the healthcare provider.

B) elevating the head of the bed for clients who are ingesting food.

A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply.) A. Orthostatic hypotension B. Tremors C. Acute dystonia D. Decreased level of consciousness E. Restlessness

B. Tremors; C. Acute dystonia; E. Restlessness Rationale: A. Orthostatic hypotension is an adverse effect, but it is not an EPS. B. Correct: Tremors are an EPS. Others are rigidity, drooling, agitation, and a shuffling gait. C. Correct: Acute dystonia is an EPS. It includes spastic movements of the back, neck, tongue, and face. D. Decreased level of consciousness is an adverse effect, but it is not an EPS. E. Correct: Restlessness is an EPS. Others are rigidity, drooling, agitation, and a shuffling gait.

Fill in the following information based on the below drug label: Brand (trade) name: Generic name: Drug form: Dosage:

Brand (trade) name: Aldomet Generic name: Methyldopa Drug form: oral suspension Dosage: 250mg per 5mL

The nurse is planning physical fitness and exercise recommendations for a 27-year-old pregnant woman at 16 weeks' gestation. The woman states that before becoming pregnant, she ran 3.5 to 4 miles on four days per week at a pace of 11 minutes per mile. She enjoys competing in 5K races and has a goal to complete a 10K race before the age of 30. Which exercise recommendation should the nurse include for this client at this stage of her pregnancy? A. Decrease the amount of exercise to 30 minutes three times per week, engaging in moderate to vigorous activity B. Continue exercising the same amount of time, but decrease the intensity of the workout to a jog or walk C. Continue engaging in vigorous activity as much as possible, with a goal of at least 150 minutes of moderate to vigorous activity per week D. Increase the amount of exercise to 60 minutes on most days of the week, most of it aerobic exercise

C Evaporation is the process of converting water to a vapor. This is the method of heat loss that occurs when a newborn baby is not dried properly. Convection is the process of heat transfer through the fluid motion of air or water across the skin. Conduction is the process of heat transfer through physical contact of one surface to another surface. Radiation is the process of heat transfer with no physical contact.

4) The nurse needs to assess the body temperature of a client who has just smoked a cigarette and consumed hot coffee. Which temperature assessment method should the nurse use? A) Axillary B) Temporal artery C) Tympanic D) Rectal

C Since the oral method cannot be used because the client smoked a cigarette and consumed hot coffee, the assessment method of choice would be the tympanic membrane. This method is readily accessible and reflects the core temperature very quickly. The rectal method is inconvenient and uncomfortable for clients. The temporal artery method requires special electronic equipment. The axillary method takes a long time if an accurate measurement is to be obtained.

While assessing a patient for posture and gait, the nurse identifies a concave cervical spine, a convex thoracic spine, and a flattened lumbar spine. Which reason should concern the nurse in the light of these findings? A. The patient may have a displaced thoracic disc. B. The findings are suggestive of a bulging cervical disc. C. The patient may have a herniated lumbar disc. D. The findings are suggestive of lordosis.

C A flattened lumbar curve and decreased spinal mobility may be evidence of a herniated lumbar disc. A convex thoracic spine is an expected finding. A concave cervical spine is an expected finding. Lordosis is associated with pregnancy or obesity.

4) A client has been started on antibiotic therapy for a respiratory infection. What would be a goal of care for this client? A) The client will have no evidence of sweating. B) The client's mucus membranes will be dry. C) The client's temperature will be within normal limits within 48 to 72 hours of the administration of the antibiotic. D) The client's temperature will approach normal within 60 minutes of the administration of the antibiotic

C A goal of care for a client receiving antibiotic therapy for an infection is for the temperature to be within normal limits within 48 to 72 hours after starting the antibiotic. The temperature approaching normal within 60 minutes would be an appropriate goal if the client were receiving antipyretics. Sweating is evidence that the temperature is decreasing, a desired outcome. Dry mucus membranes are evidence of an elevated temperature and are not a desired outcome.

8) A nurse working in an outpatient pediatric clinic is speaking to the mother of a pediatric client who has a temperature of 101°F. Which statement should the nurse include when instructing the mother on treatment of the fever? A) "Place the child in a cold bath." B) "Administer aspirin by either chewable tablet or liquid suspension." C) "It is not necessary to treat the fever at this point." D) "If your child is shivering, it is okay to use several blankets to decrease discomfort."

C Fever is not inherently harmful until it reaches 41°C (105.9°F). For this reason, medical management may include postponing treatment of low-grade fevers-those under 38.9°C (102°F) in otherwise healthy children. The child may be placed in a tepid, not cold, bath. Aspirin should not be given to children due to its link to Reye's syndrome. Reducing clothing and blankets, not additional layers, aids in the treatment of fever.

9) A nurse working in labor and delivery is aware that newborns have several physiologic mechanisms that increase heat production to prevent hypothermia. What is true regarding newborn thermogenesis? A) Shivering occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system. B) Shivering thermogenesis uses the newborn's stores of brown fat to provide heat. C) Brown fat produces heat generation, and heat transfer to the peripheral circulation. D) The extra muscular activity by the infant in cold stress produces a large amount of body heat

C In the infant, non-shivering thermogenesis (NST) occurs when skin receptors perceive a drop in the environmental temperature and transmit sensations to stimulate the sympathetic nervous system. NST uses the newborn's stores of brown fat to provide heat. Brown fat produces heat generation, and heat transfer to the peripheral circulation. The extra muscular activity by the infant in cold stress does not produce body heat.

Which type of passive exercise should the nurse implement to maintain joint mobility in an immobile patient? A. Cardiotonic B. Isometric C. Range of motion D. Resistive

C Range-of-motion exercises can be passive or active and are implemented to help maintain joint mobility. Resistive exercises are actively performed by the patient by working against resistance to increase muscle strength. Isometric exercises are used to maintain strength when a joint is immobilized. Cardiotonic is not an identified type of exercise for the musculoskeletal system.

3) The nurse assesses a client's temperature to be 99.8°F. Which nursing diagnosis would be appropriate for the client at this time? A) Hyperthermia B) Anxiety C) Risk for Imbalanced Body Temperature D) Deficient Fluid Volume

C The client's temperature is slightly elevated, which places the client at risk for an imbalance in body temperature. Hyperthermia would be indicated if the client's temperature were greater than 102°F. There is not enough information to determine whether the client is or is not experiencing anxiety or deficient fluid volume.

The nurse is preparing a patient to ambulate for the first time after a prolonged period of bedrest. The patient reports dizziness when first standing. Which action should the nurse take first? A. Immediately return the patient to bed. B. Immediately call for an ECG. C. Sit the patient on the edge of the bed until the dizziness passes. D. Call the healthcare provider.

C Vertigo or postural hypotension is common after a prolonged period of bedrest. If the patient experiences dizziness on standing, the nurse should sit the patient on the edge of the bed and wait for the dizziness to pass. It is not necessary or advisable to immediately return the patient to bed or to call the healthcare provider. Postural hypotension, not a cardiac problem, is causing the dizziness, so an ECG is not necessary.

The nurse is conducting a health history on a patient diagnosed with a spinal cord injury. Which data is most appropriate for the nurse to collect? A. Vital signs B. Spinal reflexes C. Current medications D. Bowel sounds

C When completing a health history on a patient with a spinal cord injury, the nurse needs to identify the patient's current medications. Vital signs, bowel sounds, and spinal reflexes are data obtained when completing the physical examination.

The nurse is planning care for an older adult patient with muscle atrophy and limited mobility. The nurse assigns a goal to promote comfort for the patient. Which action is most important for the nurse to include in the plan of care? A. Encourage ambulation B. Coach about isometric exercises C. Pad joints D. Teach range-of-motion exercises

C When promoting comfort, the nurse should support and pad joints and bony prominences. Encouraging ambulation might not be appropriate because the patient has muscle atrophy and limited mobility. Isometric exercises are used to maintain strength when a joint is immobilized. Range-of-motion exercises are passive exercises that help maintain joint mobility. These exercises will not necessarily promote comfort in the patient with limited mobility.

6) A client comes into the Emergency Department with a body temperature of 103°F. It is a hot and humid day, and the client works in a factory with no air conditioning. What should the nurse do to help this client? Select all that apply. A) Use warm blankets. B) Restrict fluids. C) Apply cool washcloths to the face and neck. D) Assess vital signs. E) Remove or loosen clothing around the neck and chest

C E Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it.. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) is educating the client on effective coughing techniques. Which statement made by the client indicates a need for further teaching? A) "I should inhale by sniffing." B) "I should exhale sharply with a 'huff."' C) "I should limit my fluid intake to 1-1.5 quarts daily." D) "I should cough twice and then rest."

C) "I should limit my fluid intake to 1-1.5 quarts daily."

The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS). Which statement by the nurse is appropriate? A) "You should keep the baby with you at all times to assess for apnea." B) "Make sure the baby has a soft blanket and pillow when sleeping." C) "It is recommended that you place your baby on his back for sleep." D) "SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby."

C) "It is recommended that you place your baby on his back for sleep."

A 15-year-old client with cystic fibrosis asks why she has not started her menstrual period yet. Which response by the nurse is correct? A) "Usually girls with cystic fibrosis start menstruating earlier than their peers." B) "It is normal for girls with cystic fibrosis to start their period at age 16. Just be patient." C) "Some girls with cystic fibrosis do not experience menstruation due to nutritional problems." D) "Because secretions are thicker in people with cystic fibrosis, your period will be very heavy once it starts."

C) "Some girls with cystic fibrosis do not experience menstruation due to nutritional problems."

A client asks why asthma medication is needed even though the client's last attack was several months ago. Which response by the nurse is appropriate? A) "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack." B) "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him." C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack." D) "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack."

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV. Which response by the nurse is appropriate? A) "There is a higher risk in children who are being breastfed." B) "There is no way to avoid the illness." C) "There is a higher risk in children who are exposed to secondary cigarette smoke." D) "It is seen more frequently in children who do not attend daycare."

C) "There is a higher risk in children who are exposed to secondary cigarette smoke."

The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma. Which client statement indicates a need for further teaching? A) "I need to rinse my mouth after every use of my inhaler." B) "I need to take my Singulair at least 1 hour before I eat." C) "When inhaling two different medications, I should use the bronchodilator last." D) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."

C) "When inhaling two different medications, I should use the bronchodilator last."

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis would be most appropriate for the infant? A) Acute Pain B) Ineffective Tissue Perfusion C) Activity Intolerance D) Decreased Cardiac O

C) Activity Intolerance

The nurse is providing care to a client with sepsis due to a severely infected leg wound. The client states that he is having trouble breathing. Upon assessment, the nurse notes dyspnea, a respiratory rate of 32, the use of accessory muscles to breathe, and rales and rhonchi upon auscultation of the lungs. The nurse recognizes these findings as characteristic of what condition? A) Allergic response from antibiotic therapy B) Deep vein thrombosis C) Acute respiratory distress syndrome D) Anemia

C) Acute respiratory distress syndrome

The nurse is instructing new parents on ways to decrease the risk of sudden infant death syndrome (SIDS) with their newborn son. What should be included in these instructions? Select all that apply. A) There is nothing that can be done, so requirements for toys and bedding are of no consequence. B) Instruct that it is more common in babies from ages 6 months to 18 months. C) Avoid placing the baby in the prone or side-lying position for sleep. D) Remind the parents that the syndrome is more common in females than males, and that they have a male child. E) Do not smoke near the child and reduce all exposure to secondhand smoke.

C) Avoid placing the baby in the prone or side-lying position for sleep. E) Do not smoke near the child and reduce all exposure to secondhand smoke.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client? A) Tachycardia B) Cough C) Barrel chest D) Wheezing

C) Barrel chest

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse? A) Narrow bronchi B) Narrow trachea passages C) Blocked large airway passages D) Inflamed pleural surfaces

C) Blocked large airway passages

C) Blocked large airway passages The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which conditions will you include when you teach the client's family about the types of COPD? A) Asthma and bronchitis B) Asthma and emphysema C) Bronchitis and emphysema D) Emphysema and atelectasis

C) Bronchitis and emphysema

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which assessment finding indicates that treatment has been effective? A) Client ingesting small amounts of clear fluids when encouraged B) Client resting in bed with limited interest in play or activities C) Client respiratory rate within normal limits for age D) Client coughing copious amounts of green sputum and requires occasional suctioning

C) Client respiratory rate within normal limits for age

A patient admitted with community-acquired pneumonia has been receiving oxygen therapy for several days. Which of the following assessment findings indicates an adverse effect of oxygen therapy? A) Poor skin turgor B) Copious respiratory secretions C) Cracks in the oral mucosa D) Elevated heart rate

C) Cracks in the oral mucosa

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply. A) Bounding pulse B) Pink nail beds C) Cyanosis D) Confusion E) Wheezing

C) Cyanosis D) Confusion

C) Cyanosis D) Confusion A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.

A hospital has created a culture of safety by providing organizational support for safety initiatives and by training and encouraging healthcare employees in the area of safety. What other step is needed to promote safety for everyone in the healthcare environment? A) Keep a mindset for quality of safe practice B) Post signs related to safety on the walls C) Engage clients in their own safety D) Be a safety advocate for others

C) Engage clients in their own safety Healthcare facilities should use a three-pronged approach to quality and safety for everyone, including organizational support for keeping safety a priority, encouraging employees to consistently choose to follow health safety rules and standards, and actively engaging clients in every aspect of their care, including safety. Keeping a mindset for quality of safe practice and posting signs related to safety relates to the organizational support for safety. Being a safety advocate for others is related to employees maintaining safety standards.

The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply. A) Retractions and fatigue B) Tachycardia and tachypnea C) Inaudible breath sounds D) Diffuse wheezing and the use of accessory muscles when inhaling E) Reduced wheezing and an ineffective cough

C) Inaudible breath sounds E) Reduced wheezing and an ineffective cough

A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate? A) Ineffective Airway Clearance B) Impaired Tissue Perfusion C) Ineffective Breathing Pattern D) Activity Intolerance

C) Ineffective Breathing Pattern

A client receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety related to having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply. A) Explain about care areas specifically designed for long-term ventilatory support. B) Dim the lights and reduce distracting noise, such as the television. C) Instruct that intubation and ventilation are temporary measures. D) Encourage family visits and participation in care. E) Remain with the client as much as possible.

C) Instruct that intubation and ventilation are temporary measures. D) Encourage family visits and participation in care. E) Remain with the client as much as possible.

A patient who is prescribed oxygen therapy 24 hr/day is concerned about being confined to bed. Which of the following should the nurse do to provide mobility for this patient? A) Suggest rest periods between activities of daily living. B) Allow the patient to remove the oxygen-delivery device periodically. C) Make sure the patient has up to 50 feet of connecting tubing.

C) Make sure the patient has up to 50 feet of connecting tubing.

A client diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of 93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35 bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which order does the nurse question for this client? A) Antibiotic therapy B) Nonsteroidal anti-inflammatory agents (NSAIDs) C) Oxygen by nasal cannula at 3-4 liters/minute D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

C) Oxygen by nasal cannula at 3-4 liters/minute

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate? A) Encourage strenuous activity. B) Consult a dietitian for low-calorie meals. C) Space periods of activity with periods of rest. D) Encourage dependence with activities of daily living.

C) Space periods of activity with periods of rest.

C) Space periods of activity with periods of rest. The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. It will often be appropriate to space periods of activity with periods of rest. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living.

The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate? A) Assist the child to clear the nasal passages. B) Limit fluids. C) Suction the airway to relieve the obstruction. D) Lay the child on his back.

C) Suction the airway to relieve the obstruction.

The nurse is caring for a client admitted with septic shock. Which early clinical manifestation might indicate the development of ARDS? A) Intercostal retractions B) Cyanosis C) Tachypnea D) Tachycardia

C) Tachypnea

Which is the most appropriate outcome for the nurse to select for a 78-year-old resident of a long-term care facility with regard to preventing RSV? A) The client's airways will remain clear of secretions. B) The client's fluid intake will meet daily requirements of 2000 mL per day. C) The client will demonstrate knowledge of proper hand washing techniques. D) The client will meet daily nutritional needs as provided by a nutritionist.

C) The client will demonstrate knowledge of proper hand washing techniques.

A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient? A) Simple face mask B) Nasal cannula C) Venturi mask D) Face tent

C) Venturi mask

The nurse is caring for a client with a self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this client? A) Wear hypoallergenic gloves B) Wear gloves with powder C) Wash hands after taking gloves off D) Keep beta adrenergic agonists on hand

C) Wash hands after taking gloves off The nurse should wear latex-free gloves that are hypoallergenic and powderless. Not all hypoallergenic gloves are latex-free. Powder from the gloves can absorb the latex and be transferred to clients through touch or through the air. Therefore, it is important to wash hands after removing gloves, especially gloves with powder. Beta adrenergic agonists are used for the treatment of asthma, which may develop with chronic latex exposure in a sensitive individual, but it will not affect the early symptoms of latex allergy.

The structure of the respiratory system that serves as the site of gas exchange is the A) macrophage. B) bronchi. C) alveoli. D) bronchiole.

C) alveoli.

The structure of the respiratory system that serves as the site of gas exchange is the A) macrophage. B) bronchi. C) alveoli. D) bronchiole.

C) alveoli. The alveoli comprise the terminal structures of the lower respiratory system. Alveoli serve as the sites of gas exchange, specifically, carbon dioxide and oxygen. Bronchi and bronchioles are larger structures in the respiratory system that serve as tracts for airflow. Macrophages are immune cells that keep the alveoli region free of microbes.

The primary cells involved in infection by respiratory syncytial virus (RSV) are the A) smooth muscle cells in the bronchi and bronchioles. B) granular pneumonocytes in the alveoli. C) squamous epithelial cells of the bronchioles and alveoli. D) macrophages and monocytes of the bronchioles and alveoli.

C) squamous epithelial cells of the bronchioles and alveoli.

Sudden infant death syndrome is diagnosed A) when an autopsy reveals a brainstem defect. B) when an infant dies after being shaken violently. C) when an autopsy fails to find a cause of death. D) when an infant is found dead in their crib.

C) when an autopsy fails to find a cause of death.

The nurse is teaching a client with poor peripheral perfusion about the purpose of compression stockings. Which response by the nurse would be accurate? A. "You will notice that your skin will improve with the use of these stockings as they help protect your skin from injury." B. "These stockings will help to keep your blood pressure elevated, especially when you stand too quickly." C. "These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from forming." D. "You will find that these stockings will help the heart pump more efficiently and increase the circulation to your lower extremities."

C. "These stockings will help to keep your blood pressure elevated, especially when you stand too quickly." Rationale: Compression stockings are often used by those with compromised peripheral perfusion to prevent blood from pooling in the venous system. Blood return may be slowed with poor perfusion, and blood that begins to collect in veins may form a clot. A clot that forms in leg veins may cause tissue damage and can travel up to the lungs and cause a pulmonary embolism, or it can go to the brain and cause a stroke.

A 70-year-old client is ambulating to the bathroom with assistance. The client becomes very short of breath and anxious on the way. The client begins to cry and ask for help. What is the most appropriate initial nursing intervention? A. Encourage the client to continue walking to the bathroom. B. Ask if the client would rather use a bedpan. C. Call for assistance, bring a chair, and assist the client to a sitting position. D. Quickly assist the client back to bed.

C. Call for assistance, bring a chair, and assist the client to a sitting position. Rationale: The nurse should provide reassurance and reduce anxiety. Assisting the client into a sitting position quickly and relieving anxiety is the safest and most appropriate nursing action. Assisting the client back to bed may prolong the anxiety due to needing to go to the bathroom. Encouraging the client to continue walking may increase stress. Asking if the client prefers a bedpan is appropriate but not the most immediate need.

A pediatric nurse is caring for a toddler at a well-child clinic. When providing education regarding the client's oral health, which topics are appropriate for the nurse to include? Select all that apply. A. Instructions on eliminating the client's milk consumption. B. Instructions on brushing the client's teeth once daily. C.Instructions on avoiding prolonged bottle feeding during naps and at bedtime. D. Hazards of fluoride use in tooth development. E. Instructing the parents that the client needs dental care prior to when the client begins to lose the primary teeth.

A surgical client is admitted to the ICU following abdominal surgery. Which clinical manifestation would the nurse recognize as an indication of decreased cardiac output? (Select all that apply.) A. Capillary refill less than 3 seconds B. Palpable pedal pulses C. Increased pulse rate D. Decreased urine output E. Lethargy

Checking rationale with Paula

A patient scheduled for a joint aspiration study asks the nurse what this test will show? Which response by the nurse is accurate? A. "This test is done to analyze the electrical activity of the joint." B. "This test is done to see if you have carpal tunnel syndrome." C. "This test is done to determine the electrical activity of the muscle." D. "This test is done to determine if you possibly have a fracture."

D A joint aspiration removes accumulated fluid from the joint. The fluid is analyzed to detect the presence of blood or fat droplets, which may indicate a fracture. The fluid can also be analyzed to determine if any infection is present. An electromyography (EMG) is performed to determine the electrical activity of the muscle. Joints do not have electrical activity. Nerve conduction studies are performed to determine if the nerves are functioning properly. Carpal tunnel syndrome is diagnosed through nerve conduction studies.

The nurse is caring for a patient with impaired mobility who is not able to move on their own. Which independent intervention is important for the nurse to implement? A. Prepare the patient for an electrocardiaogram (ECG). B. Instruct the patient about following a low-salt diet. C. Prepare the patient for arterial blood gas (ABG) testing. D. Perform passive range-of-motion exercises.

D A patient with impaired mobility is at great risk for contractures. If the patient is not able to exercise on their own, the nurse should perform passive range-of-motion exercises. The patient should be on a nutritious diet; low salt is not necessary unless prescribed by the healthcare provider. Electrocardiogram (ECG) and arterial blood gas (ABG) tests are collaborative interventions and not necessary in relation to the patient's immobility. An ECG tests the electrical activity of the heart. An ABG is an arterial blood gas test that measures pH and levels of oxygen and carbon dioxide. Neither is necessary for impaired mobility.

11) A nurse instructor is educating a group of student nurses regarding heat and cold injuries. The nurse includes which correct statement regarding thermoregulation? A) "Core temperature varies widely depending on the outside environment." B) "The body's surface temperature remains relatively constant." C) "Chemical thermogenesis occurs with the increase of cortisol." D) "All muscle activity, regardless of location, produces heat

D All muscle activity, regardless of location, produces heat. Core temperature remains relatively constant, whereas the body's surface temperature varies widely depending on the outside environment. Chemical thermogenesis occurs with increased thyroxine output, not cortisol.

8A client is prescribed medication for an elevated body temperature. What would be appropriate for the nurse to provide to the client? A) Muscle relaxant B) Antihypertensive C) Sedative D) Antipyretic

D Antipyretic medication is used to reduce the body temperature. Antihypertensives are used to reduce blood pressure. Muscle relaxants and sedatives do not reduce body temperature.

The nurse is caring for a pregnant patient diagnosed with cauda equina syndrome. Which procedure should the nurse expect to prepare the patient to undergo? A. CT scan B. MRI C. X-rays D. Surgery

D Cauda equina syndrome, compression of the nerve roots of the cauda equine, is the only condition for which surgery is absolutely indicated in pregnant women. It can result in permanent neurologic impairment, including urinary incontinence and paralysis. It is considered a medical emergency. Causes include massive lumbar disc herniation, spinal stenosis, epidural hematoma, epidural abscess, and trauma. X-rays, CT scans, and MRIs are diagnostic exams.

2) An older client with a history of congestive heart failure has a low-grade fever. What should the nurse do? A) Provide warm blankets. B) Restrict fluids. C) Encourage getting out of bed to ambulate. D) Notify the physician.

D Clients with chronic conditions such as congestive heart failure should be further evaluated by the physician as to the cause of the fever. The nurse should not restrict the client's fluids. Providing warm blankets might make the client more uncomfortable. The client should not be encouraged to perform activity until the source of the fever has been identified.

Which laboratory test result should indicate to the nurse that the patient requires vitamin D supplements? A. Increased uric acid B. Decreased creatine kinase C. Presence of human leukocyte antigen-B27 (HLA-B27) D. Decreased phosphorous

D Decreased levels of phosphorous may indicate a lack of vitamin D. The presence of human leukocyte antigen-B27 (HLA-B27) indicates an increased risk for ankylosing spondylitis and arthritis. Creatine kinase is used to determine muscle damage. Uric acid levels are used to assess for gout, excessive exercise, and other nonmusculoskeletal health problems.

3) What should the nurse instruct the parents of a family planning an ice fishing trip with their three children, all under the ages of 10, regarding hypothermia? A) All family members should wear skid-proof footwear. B) If someone becomes hypothermic, keep the clothing on, cover the person with damp blankets, and have the person drink a cool liquid. C) All family members should wear thick outerwear. D) If someone becomes hypothermic, remove any wet clothing, wrap the person in blankets, and have the person drink a warm liquid

D First aid for hypothermia includes moving the person to a dry area, removing wet clothing, protecting the person from further environmental exposure, wrapping the person in dry blankets, dressing the person in warm and dry clothing, and having the person drink a warm, high-calorie liquid. Wet clothing should be removed. Dry blankets should be used. Warm liquids should be provided. Skid-proof footwear and thick outerwear will not prevent hypothermia in all cases.

The nurse is caring for a patient who wears a brace on their right ankle. Which action should the nurse take first? A. Remove the brace when the patient uses the bathroom. B. Assess the right foot for redness. C. Wash and dry the area covered by the brace. D. Assess the right foot for impaired sensation.

D For a patient with a brace, it is most important for the nurse to assess the circulation of the surrounding area first. The nurse should frequently and routinely check for symptoms of circulatory impairment, including skin pallor or blanching (not redness), weak or absent pulses, and impaired sensation. An ankle brace does not need to be removed when the patient uses the bathroom. It is more important to check the circulation than to wash and dry the leg or foot.

7) A client is admitted with a core body temperature of 93°F. What should the nurse do to improve this client's body temperature? A) Apply warm soaks to the extremities. B) Use a hyperthermia blanket. C) Provide warm fluids. D) Use warm blankets

D For mild hypothermia, or a body temperature of 90-95°F, use warm blankets. For severe hypothermia, use a hyperthermia blanket. Warm soaks to extremities will not raise the client's body temperature and might cause chilling. Providing warm fluids is beneficial but not enough to raise the client's body temperature.

9) A nurse is caring for a client with a fever who also has an increased respiratory rate. What is true regarding this client's condition? A) The decrease in prostaglandin production causes the respiratory rate to increase. B) Although it sometimes occurs, an increased respiratory rate is not a common reaction to fever. C) One degree of temperature elevation causes an increase in respiratory rate by two breaths per minute. D) One degree of temperature elevation causes an increase in respiratory rate by four breaths per minute.

D Increased respiratory rate always occurs with a fever. Every one degree of temperature elevation causes an increase in respiratory rate of four breaths per minute. Prostaglandin production increases, not decreases during fever.

A patient is scheduled for a magnetic evoked potentials exam. Which explanation should the nurse use in educating the patient about the test's purpose? A. "It is used to examine diseased structures in the spinal cord." B. "It identifies fractured vertebrae." C. "It is used to determine the level of the spinal cord that is damaged." D. "It measures how nerves respond to different types of stimulation."

D Magnetic evoked potentials can be used to detect neural response to physiological, electrical, or magnetic stimulation. Common sites for stimulation include the median nerve, the common peroneal nerve, and the posterior tibial nerve. MRIs and CTs are used to determine the level of the spinal cord that is damaged, not to measure nerve conduction. Spinal x-rays identify fractured vertebrae; they do not measure neural response.

A patient with impaired mobility needs assistance with completing activities of daily living (ADLs). The nurse should request a referral for which collaborative rehabilitation service? A. Music therapy B. Speech therapy C. Physical therapy D. Occupational therapy

D Occupational therapists help a patient maintain and optimize skills that are necessary to complete activities of daily living (ADLs). They can also recommend modifications to the patient's home environment to allow the patient to become more independent. Physical therapists help the patient to preserve or regain mobility. Speech therapy deals with speech and swallowing issues. Music therapy is used for psychological issues.

The nurse is teaching the family of a patient with an alteration of mobility how to protect the patient from injury. Which instruction about the patient's environment is appropriate for the nurse to include? A. "Keep the lights turned down low." B. "Encourage the patient to learn something new." C. "Avoid helping the patient do things they can do for themselves." D. "Watch for slip hazards like loose carpets on the floor."

D Preventing injury is a goal for the patient with an alteration of mobility. The patient's environment should be screened for potential hazards like loose floor coverings. Lights should be kept at adequate levels so the patient can clearly see to move. Avoiding helping someone do what they can do for themselves and encouraging them to learn something new are interventions that foster independence, not protect the patient from injury.

The nurse presents genetic factors that might affect mobility to a community group. Which genetic factor listed by a community member should lead the nurse to provide further teaching? A. Marfan syndrome B. Muscular dystrophy C. Amyotrophic lateral sclerosis D. Sickle cell disease

D Sickle cell disease is a condition that affects the blood vessels, not mobility. Muscular dystrophy is characterized by progressive weakness and degeneration of skeletal muscles. Marfan syndrome is a disorder of connective tissues that causes pain, numbness, and weakness in the legs. Amyotrophic lateral sclerosis is a neurologic disorder that affects voluntary muscle movement.

During morning assessment, the nurse observes that a patient is not moving as well they were moving the previous morning. Which assessment question by the nurse is most appropriate? A. "Are you feeling like you want to sleep more?" B. "Did you get up during the night?" C. "How did you sleep last night?" D. "Are you having any pain this morning?"

D Since pain is a very likely cause of decreased mobility, the nurse should focus first on assessing if this is the problem. While the other questions are appropriate to ask during the assessment, they are not the priority to determine the cause of more limited movement.

4) A client has a body temperature of 95°F and exhibits slurred speech and poor coordination. Which nursing diagnosis is the priority for the client at this time? A) Disturbed Sensory Perception B) Acute Confusion C) Hypothermia D) Imbalanced Body Temperature

D The client is demonstrating signs of a mild reduction in body temperature. The nursing diagnosis appropriate at this time is Imbalanced Body Temperature. A body temperature below 90°F would indicate hypothermia. Confusion is a manifestation of mild hypothermia and not the priority nursing diagnosis. Sensory impairment may or may not be present in this client.

8) A client has a body temperature of 94°F, irregular heart rate, and low blood pressure. What would be the most beneficial nursing intervention for this client? A) Elevate the client's legs. B) Provide a heating pad to the client's lower back. C) Elevate the head of the bed. D) Administer warmed intravenous fluids

D The client is mildly hypothermic with symptoms of an irregular heartbeat and low blood pressure. Warmed intravenous fluids would be beneficial for this client. Elevating the legs or the head of the bed will not help with the client's hypothermia. A heating pad to the lower back is not indicated in the treatment of hypothermia.

The nurse is developing a plan of care for an immobile patient and is concerned about skin integrity. Which intervention is appropriate for the nurse to include? A. Allow the patient to sit up in a chair for as long as possible. B. Reposition the patient every 4 hours. C. Give the patient's skin a brisk rubdown daily. D. Turn the patient every 2 hours.

D To maintain skin integrity in an immobile patient, the nurse should encourage and facilitate activities that safely promote mobility, including turning and repositioning the patient every 2 hours. Briskly rubbing the patient's skin could cause it to break down. Having the patient sit in one position for long periods could cause skin breakdown.

The nurse is planning care for an older adult patient with muscle atrophy and limited mobility. The nurse pads the patient's joints. Which explanation for this action should the nurse provide to the patient? A. "This will encourage you to ambulate more." B. "These pads are necessary for you to do isometric exercises." C. "These pads will help you with range-of motion exercises." D. "Padding your joints should increase your comfort."

D When promoting comfort, the nurse should support and pad joints and bony prominences. Encouraging ambulation might not be appropriate because the patient has muscle atrophy and limited mobility. Isometric exercises are used to maintain strength when a joint is immobilized. Range-of-motion exercises are passive exercises that help maintain joint mobility. These exercises will not necessarily promote comfort in the patient with limited mobility.

A client who is recovering from a spontaneous arm fracture is prescribed a calcium supplement. Which information is most appropriate for the nurse to explain about the relationship between calcium and bone strength? A. "Calcium fills in the spaces caused by the fracture." B. "The thyroid gland works to make calcium." C. "Calcium helps breakdown of bone tissue." D. "The body will break down bone if calcium levels are low."

D Rationale: Bone resorption is the process where bone is broken down and minerals are released into the bloodstream. Resorption occurs when the minerals are needed for other body functions. When calcium levels are low, the parathyroid hormone is released to cause osteoclast action or activity that breaks down bone tissue. The breakdown increases blood calcium levels. If calcium levels in the blood are elevated, calcitonin is released, which stops osteoclast activity and increases mineralization of bones. Calcium does not break down bone tissue. The thyroid gland does not make calcium. Calcium does not fill in the spaces caused by the fracture.

During a well-child visit, a female high school student complains about their inability to do as much physically as their twin brother. Which response by the nurse is accurate? A. "Girls need to eat more to have more muscle." B. "Muscle growth in girls peaks at age 13." C. "Girls have less muscle after the age of 16." D. "Boys have more muscle mass than girls."

D Rationale: Boys have more muscle mass than girls. Muscle growth in girls peaks between the ages of 16 and 20. Eating more will not increase the amount of muscle. Boys and girls have the same amount of muscle until age 13.

Which assistive device should the nurse expect to be ordered for an older client who is unsteady when ambulating? A. Cane B. Lofstrand crutches C. Axillary crutches D. Walker

D Rationale: For older, unsteady adults, the best assistive device for ambulation is a walker. A walker provides maximum stability for the client. Crutches can be unsteady for older adults to use, and a cane is used only when a minimum amount of support is required.

A client is prescribed a nonsteroidal anti-inflammatory drug (NSAID) for arthritis. Which information should the nurse teach the client about this medication? A. Take this medication with calcium supplements. B. This medication may cause confusion and hallucinations. C. Avoid driving or using machinery while taking this medication. D. Report any gastrointestinal distress to the healthcare provider.

D Rationale: NSAIDs can cause gastrointestinal distress, which should be reported to the healthcare provider. Calcium supplements do not need to be taken with NSAIDs. Antispasmodics can cause confusion and hallucinations. Driving and machinery use should be restricted when taking an antispasmodic.

A client with altered mobility is unable to bear weight on their wrists. Which type of assistive device should the nurse expect to be prescribed for the client? A. Cane B. Axillary crutches C. Lofstrand crutches D. Platform crutches

D Rationale: Platform crutches are used for clients unable to bear weight on their wrists. When using axillary crutches, the body weight is supported by the wrists. Lofstrand crutches use a forearm piece for stability, but the weight is still supported by the wrists. A cane is less supportive than crutches, and the body weight is still supported on the wrist.

3) A client is experiencing an elevated temperature. What should the nurse include in this client's plan of care? Select all that apply A) Administer warm intravenous fluids. B) Apply warm blankets. C) Provide dry clothing. D) Increase oral fluid intake. E) Administer antipyretic medication

D E The client has an elevated temperature. The administration of antipyretic medication is one treatment used to lower the body temperature. Increasing oral fluid intake is an intervention for an elevated body temperature. The other options would be interventions to help a client with a lower body temperature.

D E The client with an elevated body temperature should be encouraged to ingest fluids or should be provided with IV fluids. The increase in body temperature could be due to dehydration. Another intervention to help the client with an elevated temperature is to lower the room temperature. The client's fluids should not be restricted. Blankets and providing a warm room would be applicable if the client had a low body temperature.

A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is best? A) "The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than usual." B) "You don't need to worry about posters on the wall. Our primary concern is getting you well." C) "We never make mistakes here. We want the public to know that we have client safety goals here." D) "There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them."

D) "There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them." Client safety initiatives address collaborative efforts by staff and clients to promote safety in healthcare settings. These initiatives require collaboration by all members of the team, including clients. Mistakes can occur in all healthcare settings; behaviors, not goals, help to prevent them.

For couples in which both individuals carry one defective CF gene, any offspring from the couple has a ________ percent chance of inheriting two abnormal genes and developing cystic fibrosis. A) 100 B) 75 C) 50 D) 25

D) 25

Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift should the nurse recommend for this client? A) A basket of flowers B) A stuffed animal C) Fruit and candy D) A book

D) A book

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client's risk for developing a respiratory infection? A) A broad-spectrum antibiotic B) A bronchodilator C) A corticosteroid D) An influenza vaccine

D) An influenza vaccine

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client? A) Hemoglobin level 14 g/dL B) Oxygen saturation 96% C) Serum sodium 140 mg/dL D) Blood pH 7.32

D) Blood pH 7.32

D) Blood pH 7.32 Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.

The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS). Which action by the nurse is appropriate? A) Advising the parents that an autopsy is not necessary B) Refraining from recommending support groups until after the investigation C) Interviewing the parents to determine the cause of the SIDS incident D) Contacting the family's spiritual leader for support

D) Contacting the family's spiritual leader for support

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate? A) Notify the healthcare provider of this assessment finding. B) Obtain an arterial blood gas for further respiratory assessment. C) Begin monitoring the respiratory rate every 5 minutes. D) Continue to monitor the newborn per facility policy.

D) Continue to monitor the newborn per facility policy.

D) Continue to monitor the newborn per facility policy. A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute. Therefore, this client only needs monitoring. No other actions are necessary.

Which assessment finding by the nurse supports the diagnosis that a client is in the early stages of chronic obstructive pulmonary disease (COPD)? A) Dysrhythmias B) Cyanotic nail beds C) Clubbing of the fingers D) Cough in the morning producing clear sputum

D) Cough in the morning

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)? A) Fluid imbalance B) Hypertension C) Bradycardia D) Dyspnea

D) Dyspnea

The nurse is caring for a woman who is 32 weeks pregnant and requires mechanical ventilation for ARDS. In addition to standard nursing interventions for adult clients with ARDS, what special interventions need to be implemented for this client? A) Inducing labor B) Administering nitric oxide and corticosteroids C) Providing nutritional support D) Fetal monitoring

D) Fetal monitoring

The nurse is assessing an adult client with respiratory syncytial virus (RSV). Which symptom will the nurse expect to assess that is not seen in infants with RSV? A) Rhinorrhea B) Cough C) Apnea D) Headache

D) Headache

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the priority for this client? A) Ineffective Coping B) Ineffective Airway Clearance C) Anxiety D) Ineffective Breathing Pattern

D) Ineffective Breathing Pattern

The nurse is providing care to a 7-month-old child hospitalized with RSV/bronchiolitis. The nurse can expect to provide client teaching to the parents about which medication? A) Corticosteroids B) Nebulized epinephrine C) Antibiotics D) Nebulized hypertonic saline

D) Nebulized hypertonic saline

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client speaks very little English and is a smoker. Which action would be the most beneficial for this client? A) Have the adult child of the client translate during the assessment process B) Encourage aerobic activity C) Encourage the client to write down questions prior to seeing the healthcare provider D) Obtain educational materials about smoking cessation written in Spanish.

D) Obtain educational materials about smoking cessation written in Spanish.

The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange? A) Provide adequate rest periods B) Reduce excessive stimuli C) Assist with activities of daily living D) Place in Fowler position

D) Place in Fowler position

The nurse is caring for a 230-lb client who needs to be repositioned every 2 hours. While repositioning the client, the nurse injured a muscle in her back. To prevent the injury and ensure safety for both the nurse and client, what should the nurse have done differently in this situation? A) She should have used proper lifting techniques. B) She should have repositioned the client only if the client requested it. C) She should have questioned the physician about the need to reposition the client. D) She should have asked for help from another nurse.

D) She should have asked for help from another nurse. When moving or repositioning clients, especially larger clients, the nurse should always ask for help from another healthcare worker to prevent injury. Although using proper lifting techniques is important, they do not guarantee that injuries will not occur. In addition, there is no evidence that the nurse was not already using proper lifting techniques. The nurse should question physician orders if she is unclear about the reasoning for the order, but this is a standard best practice and would likely not require questioning. The nurse should reposition the client as ordered, not only when the client requests it.

A nurse should recognize that which of the following is an indication for oxygen therapy? A) Respiratory rate 32/min; anxiety B) Dyspnea; PaO2 90 mm Hg C) Chest pain; FiO2 65% for 4 days D) Tachypnea; SaO2 90%

D) Tachypnea; SaO2 90%

The nurse is planning care for a new mother who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby? Select all that apply. A) Information on bottle-feeding the infant B) Reasons why the child should sleep with others C) Ages at which the child should receive immunizations D) Using bedding that is firm E) Smoking cessation information

D) Using bedding that is firm E) Smoking cessation information

A nurse is providing discharge teaching to a patient who will continue oxygen therapy at home. The nurse should instruct the patient that turning the knob on the oxygen flow meter all the way to the right A) starts the flow of oxygen. B) provides the maximal oxygen flow. C) provides a minimal oxygen flow. D) stops the flow of oxygen.

D) stops the flow of oxygen.

A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can open the capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding." C. "I can crush the pills with the coating on them." D. "I will eat two crackers with the pain pills."

D. "I will eat two crackers with the pain pills." Rationale: A. Although this might help a client who has swallowing issues, it is essential for the client to swallow enteric-coated or time-release medications whole. B. Although adding a liquid medication to food is helpful if the client is having difficulty swallowing, he should not mix the medication with large amounts of food or beverages in case he cannot consume the entire quantity. C. The client must not crush enteric-coated or time-release preparations. He must swallow them whole. D. Correct: The client should take irritating medications, such as analgesics, with small amounts of food. It can help prevent nausea and vomiting.

You are reading the physicians orders & note date & time of the prescriptions, as well as the physicians signature. WhichDIo of the following prescriptions is complete? -Aspirin PO 1 tablet daily -Ferrous sulfate 624 mg PO -Hydrocodone/acetaminophen 5/325 mg PRN -Digoxin (Lanoxin) 1.25 mg PO daily

Digoxin (Lanoxin) 1.25 mg PO daily

For which of the following inhalation medication delivery methods is it important for the nurse to assess the patient's ability to inhale deeply before administering the medication? Dry powder inhaler (DPI) Nasal spray Metered dose inhaler (MDI) with attached spacer Use of a nebulizer via a mask

Dry powder inhaler (DPI)

A nurse is caring for a client who arrived at an emergency department following a bee sting. Which of the following findings indicates an anaphylactic reaction? (select all that apply) [] low blood pressure [] wheezing [] bradycardia [] peripheral edema [] difficulty swallowing

Low blood pressure is correct. *Anaphylaxis is an immediate and life-threatening allergic response, manifesting as bronchospasm, laryngeal edema, and a rapid drop in blood pressure. Immediate treatment with epinephrine and IV fluids is imperative. Wheezing is correct. *Anaphylaxis is an immediate and life-threatening allergic response, manifesting as bronchospasm, laryngeal edema, and a rapid drop in blood pressure. Wheezing is an indication of bronchospasm and is treated using bronchodilators. Difficulty swallowing is correct. *Anaphylaxis is an immediate and life-threatening allergic response, manifesting as bronchospasm, laryngeal edema, and a rapid drop in blood pressure. Difficulty swallowing is an indication of laryngeal edema and, therefore, anaphylaxis.

A nurse is preparing to teach a client how to take care of a newly created colostomy. The nurse should identify that which of the following factors can decrease the client's ability to learn? (select all that apply) [] impaired cognitive level [] language barrier [] discomfort [] repetition of teaching [] unreadiness to learn

[] impaired cognitive level [] language barrier [] discomfort [] unreadiness to learn

A nurse is providing teaching for a client who has a new prescription for a drug with a high potential for toxicity. Which of the following information should the nurse include? (select all that apply) [] periodic laboratory tests are essential to measure serum drug levels [] monitoring for indications of toxicity is important [] taking the drug with an inducing agent will increase the possibility of toxicity [] taking the smallest effective dose is crucial [] increasing fluid intake is recommended to avoid toxicity

Periodic laboratory tests are essential for measuring serum drug levels is correct. *Clients who are taking drugs that have a high potential for toxicity should undergo regular monitoring of serum drug levels to be certain the drug level stays within the therapeutic range. Monitoring for indications of toxicity is important is correct. *Drugs that have a high potential for toxicity can quickly build up to toxic levels in the blood, resulting in effects that can be irreversible or life-threatening. Therefore, the nurse should monitor for manifestations of toxicity particular to the drug the client is taking. Taking the smallest effective dose is crucial is correct. *It is optimal to use the lowest effective dose of a drug to achieve therapeutic effects because doing so helps minimize the risk for toxicity.

A nurse is caring for a client who was prescribed an antidepressant based on its ability to prevent the reuptake of neurotransmitters. The nurse should identify that which of the following terms describes why this drug was prescribed for the client? [] pharmacologic action [] chemical stability [] route [] adverse effects

Pharmacologic action is Correct The nurse should identify that the mechanism of action of a drug on the body to achieve the desired effect is referred to as pharmacologic action. Chemical stability The nurse should identify that knowledge of how a drug should be stored and handled to maintain maximum effectiveness is referred to as chemical stability. Route The nurse should identify that route refers to the method of administering the drug, such as oral, topical, or parenterally. Adverse effects The nurse should identify that adverse effects refer to the unintended and undesired effects that drugs have on the body, which can range from annoying to life-threatening.

A nurse is performing an assessment on a 65-year-old client. Which subjective assessment finding could indicate a decrease in perfusion? A. Decreased appetite B. Reporting the need for a mid-afternoon nap C. Sleeping with more pillows or in a recliner D. Nocturnal leg cramping

Rationale: A person who develops decreased perfusion over time may require more pillows at night in order to sleep in an upright position, which could make breathing easier. A client who reports needing additional pillows or feeling short of breath at night should have further evaluation. Decreased appetite could be related to illness or medication, and needing a mid-afternoon nap may be an effect of aging. Nocturnal leg cramps are usually sudden spasms of muscles in the calf, which may be due to exercise, electrolyte imbalance, dehydration, medication, pregnancy, or other medical conditions.

A nurse is caring for a client who is postpartum and breastfeeding. The client asks the nurse about the effects that taking over-the-counter drugs will have on her newborn. Which of the following should the nurse consider when recommending a drug for the client? (select all that apply) [] the newborn's weight [] how much breast milk the newborn consumes each day [] whether or not the benefits to the client outweigh the risks to the newborn [] the properties of the drug [] the route of administration of the drug

The newborn's weight is correct. *The nurse should consider the weight of the newborn when recommending a drug for a client who is breastfeeding. The lower the newborn's weight, the greater the effects of the drug absorbed via breastmilk will be to the newborn. How much breast milk the newborn consumes each day is correct. *The nurse should consider the amount of breast milk the newborn consumes per day when recommending a drug for a client who is breastfeeding. The more breast milk the newborn consumes, the more of the drug is likely to be absorbed into the newborn's circulation. Whether or not the benefits to the client outweigh the risks to the newborn is correct. *The nurse should weigh the benefits against the risks when recommending a drug for a client who is breastfeeding. If the benefits will be minimal, it is generally not worth the risk to the newborn. The properties of the drug is correct. *The nurse should consider the properties of the drug when recommending a drug for a client who is breastfeeding. Certain drugs can transfer more easily into breast milk, depending on properties like fat solubility.

When reviewing a list of drugs in a drug handbook, a nurse can identify the generic name for a drug in which of the following ways? [] it begins with a lower-case letter [] it is listed in parentheses along with the trade name [] there are both letters and numbers in the name [] the chemical name is listed in parentheses before the generic name

[] it begins with a lower-case letter

A nurse is administering aspirin 81 mg PO daily as prescribed. The medication is scheduled for 0800 hours. Which of the following demonstrates proper use of one of the six rights of medication administration? The nurse performs the first check of the correct dosage at the patient's bedside. The nurse identifies the patient by stating the patient's name as written on the medication administration record. The nurse documents that the aspirin was given at 0825. The nurse opens the 81 mg aspirin unit dose package prior to entering the patient's room.

The nurse documents that the aspirin was given at 0825.

An 8-month-old child is prescribed acetaminophen (Tylenol) elixir for management of fever. She is recovering from gastroenteritis and is still having several loose stools each day. The child spits some of the elixir on her shirt. Should the nurse repeat the dose? What are the implications of this child's age and physical condition for oral drug administration?

The nurse should consult with the pharmacist regarding the need to repeat the dose. Many oral elixirs are absorbed to some degree in the mucous membranes of the oral cavity. Therefore, the nurse may not need to repeat the dose. The nurse should consider using an oral syringe to accurately measure and administer medications to infants. The syringe tip should be placed in the side of the mouth, not forced over the tongue. Conditions affecting the GI tract, such as gastroenteritis, can affect drug absorption because of their effect on increasing peristalsis.

A nurse is caring for a client who is receiving nitroglycerin IV and is switching to the oral form of the drug. The nurse should identify that the oral dose will be higher than the IV dose for which of the following reasons? [] the IV form crosses the blood-brain barrier [] the oral form has a decreased half-life [] the oral form has decreased bioavailability because of the first-pass effect [] the oral form has an increased rate of excretion

The oral form has decreased bioavailability because of the first-pass effect Oral doses are often larger than IV doses of the same drug because of the first-pass effect by the liver, which reduces the bioavailability of the drug. Enzymes in the liver metabolize drugs, making less of the drug available for use by the body.

Which of the following is the most appropriate documentation of a patient's response to a pain medication? -The patient states, "I feel better" 10 min after medication administration -The patient is sleeping 1 hr after administration -The patient is up & walking in the hall 2 hrs after administration -The patient reports pain decreased to 3/10, 30 min after medication administration

The patient reports pain decreased to 3/10, 30 min after medication administration

A nurse is preparing to teach a client about a newly prescribed drug. Prior to providing teaching, the nurse should review the precautions section of a drug handbook for which of the following reasons? [] to determine drug-food interactions [] to determine if dosage modification is indicated [] to determine how the drug is absorbed [] to determine availability

To determine if dosage modification is indicated The precautions section includes diseases or clinical situations in which drug use involves particular risks or dosage modification might be necessary, such as the presence of a client condition or restrictions due to the client's age.

A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. Which of the following should the nurse do to locate the appropriate site? -Measure two finger breadths below the acromion process -Measure a hand breadth below the knee & a hand breadth below the greater trochanter -With the heel of the hand on the greater trochanter, point the index finger up toward the anterior superior iliac spine, extending the other fingers back along the iliac crest -Divide the buttock into 4 quadrants, & administer injection in the upper, outer quadrant

With the heel of the hand on the greater trochanter, point the index finger up toward the anterior superior iliac spine, extending the other fingers back along the iliac crest

A patient is to receive his daily isoniazid (INH) dosage for tuberculosis. He states he is feeling nauseated with this medication and refuses to take it. The nurse knows that the correct way to indicate this refusal is to document the reason for refusal along with the date and time in the patient's medical record. circle the scheduled time of medication administration on the medication record. initial the scheduled time of medication administration on the medication record. notify the primary care provider that the patient refused to take the medication.

document the reason for refusal along with the date and time in the patient's medical record.

A nurse is providing teaching to a pregnant client who is taking captopril, an ACE inhibitor, to treat hypertension. The nurse informs the client that captopril is a teratogenic drug. The nurse should explain that teratogenic drugs can cause which of the following? [] maternal bleeding [] maternal blood clots [] gestational diabetes mellitus [] fetal malformation

fetal malformation Teratogenic drugs can cause birth defects. Clients who are pregnant should not take these drugs.

A nurse will be administering several medications to a patient who is receiving enteral feedings through a small bore nasogastric tube. The nurse administers the medications correctly by adding crushed medications to the enteral tube feedings and infusing via an electronic pump. infusing each medication by gravity and flushing with water before and after instillation. administering medications through a large bulb syringe. lowering the syringe to promote instillation of medication.

infusing each medication by gravity and flushing with water before and after instillation.

A nurse is reviewing drugs in a drug reference. The nurse should identify that drugs in the same class share which of the following similarities? [] they have similar mechanisms of actions [] they have the same half-life [] they are administered by the same route [] they have similar availability

they have similar mechanisms of actions Drugs in the same class often share similar mechanisms of action, as well as assessment guidelines, interactions, and precautions.

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