Hesi (Fundamentals study guide)

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic Rationale: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.

A client diagnosed with chronic kidney disease is being treated at home with continuous ambulatory peritoneal dialysis. The client notes that there is a decrease in the catheter outflow following the prescribed 6-hour dwell time and calls the nurse to report this occurrence. The nurse should reinforce instructing the client to take which action?

Ambulate in the home. Rationale: The most common causes of decreased outflow of dialysate in peritoneal dialysis are displacement and obstruction of the catheter. Obstruction may be a result of malposition, adherence of the catheter tip to internal organs, constipation, or infection. The client with decreased catheter outflow should first attempt to displace the catheter tip from internal organs by changing positions or walking. This may be a simple solution to the problem. If the client has been constipated, treatment of the constipation would be necessary. The health care provider need not be notified immediately, unless the client is exhibiting signs of infection or if attempts to noninvasively clear the obstruction are not effective. Straight catheterization of the bladder will not alleviate this problem, and the client should never instill any type of medication into the catheter besides the medications contained in the dialysate solution.

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

Client threatened to commit suicide Client threatened to kidnap his spouse. Rationale: Involuntary admission criteria include imminent danger to self or others and the inability to care for one's own basic needs. Threatening to commit suicide and kidnapping one's spouse meet these criteria. Not bathing in 2 days and not taking antipsychotic medications reflect the client's autonomy in self-care and writing a document in chalk on the sidewalk is eccentric but presents no danger to the client or others.

A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which finding would indicate that the client is experiencing side/adverse effects related to this medication? Select all that apply.

Constipation Bleeding gums Decreased platelet count Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily

A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply.

Cool to touch Swelling at the site May not have a blood return Rationale: An infiltrated IV is one that has dislodged from the vein, and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line. The other options indicate phlebitis.

As the nurse approaches a client who was recently admitted to the inpatient unit of a psychiatric hospital, the client says, "Quit following me. You're with the Federal Crime Scene Investigation Unit; I can tell by the way you are walking." This is an example of which alteration in thinking?

Delusion Rationale: Delusions are false fixed beliefs that cannot be corrected by reasoning. Most commonly, delusional thinking involves themes of ideas of reference, persecution, grandiosity, jealousy, and control. Hallucinations are defined as sensory perceptions for which no external stimulus exists. The most common types of hallucinations are auditory, visual, olfactory, and tactile. Circumstantiality is a pattern of speech characterized by indirectness and delay before a person gets to the point or answers a question. The client gets caught up in countless details and explanations. Associative looseness is an alteration in speech consisting of threads (associations) that tie one thought or concept to another.

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse should determine that this is an expected finding if the client had which health problem?

Diarrhea Rationale: A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. The client with Cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia.

The nurse is reinforcing instructions to a Native-American client regarding the procedure for collecting a urine sample. The nurse observes that the client continually stares at the floor during the instructional session. The nurse interprets this as being indicative of which behavior?

Embarrassment Rationale: Native-American clients often stare at the floor when the nurse is talking. This culturally appropriate behavior indicates that the listener is paying close attention to the speaker. Options 1, 2, and 4 are inappropriate interpretations of the client's behavior.

A client has arrived in the clinic complaining of dyspepsia and pain that occurs about 90 minutes after eating. The client also reports that the pain got worse this afternoon about 3 hours after eating a large bowl of spaghetti with tomato sauce. Laboratory tests reveal the presence of Helicobacter pylori (H. pylori). The nurse anticipates that the health care provider will prescribe which medications? Select all that apply.

Esomeprazole (Nexium) Metronidazole (Flagyl) Clarithromycin (Biaxin Rationale: The client is describing symptoms associated with a duodenal ulcer. Clarithromycin and metronidazole are two of the antibiotics frequently prescribed to treat H. pylori infection, which is a common cause of duodenal ulcers. A proton pump inhibitor, like esomeprazole, is prescribed to help decrease gastric acid secretions. Tums is contraindicated because it can trigger gastrin release resulting in rebound acid secretion and more pain. The ibuprofen (like all NSAIDs) can aggravate the ulcer.

A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.

Get plenty of sleep and rest. Take all medications as prescribed. Eat plenty of fresh fruits, salads, and vegetables. Wash your hands frequently with antibacterial soap. Rationale: Neutropenic precautions require that the individual protect self from infection. Getting adequate sleep and rest helps prevent infection. All medications must be taken as prescribed; if there is a problem, the health care provider is contacted. Washing hands frequently with antibacterial soap or alcohol-based hand sanitizer is a major part of avoiding infection. Fresh fruits, salads, and vegetables contain bacteria and, unless cooked, could cause infection. Plants and flowers contain bacteria and cannot be sanitized; therefore, they exposure should be avoided.

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?

It is specifically designed for short-term use. Rationale: PICC catheters are intended to be used for clients who need long-term catheter placement. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral IV catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of different types of medications.

The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Before administering the medication, the nurse routinely screens for which signs/symptoms that could indicate early signs of digoxin toxicity?

Loss of appetite, nausea, and vomiting Rationale: Loss of appetite and nausea are early signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (e.g., green and yellow vision or seeing spots or halos), confusion, vomiting, or diarrhea

A client is suspected of having a myocardial infarction. The nurse should expect elevations in which isoenzyme value reported with the creatine kinase (CK) level?

MB Rationale: The MB band reflects CK from cardiac muscle, which is the level that increases with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There is no MK band.

A client is being discharged with a prescription for propranolol (Inderal). When reinforcing instructions to the client about the medication, the nurse should include which information?

Medication should be withheld if the pulse rate drops below 60 beats per minute Rationale: Most beta blockers may be administered with food or on an empty stomach, but propranolol is absorbed best if taken with meals or directly after eating. Exercise will not prevent orthostatic hypotension. Hot showers and baths are not advised because of their vasodilating effect. The client needs to be instructed how to take the pulse rate and to notify the health care provider if the heart rate falls below 60 beats per minute

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention

Monitoring for the gag reflex Rationale: To prevent aspiration, the client may not eat or drink after this procedure until protective airway reflexes return. The nurse must document that the gag and swallow reflexes have returned. The client would receive a local anesthetic to the throat before the procedure, not after. Positioning restrictions are not necessary following the procedure.

A mental health nurse is assigned to care for a client with a diagnosis of schizophrenia, acute phase. The nurse should use which approach when planning care for this client?

Provide assistance with grooming and nutrition until the client's thinking is cleared. Rationale: In the acute phase of schizophrenia, the nurse must assume responsibility for planning the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. Options 1 and 2 are incorrect, because these actions do not provide a structured routine. Option 4 is a nontherapeutic communication technique

A client is being given a transcutaneous electrical nerve stimulation (TENS) unit to use for relief of chronic pain. Which instructions should the nurse reinforce to the client about the TENS unit? Select all that apply.

Using this unit will help relieve the pain.

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

"I notice you are wearing a blue shirt." "Do you have any plans of harming yourself?" "I will sit here with you even if you choose not to talk with me." Rationale: Assisting the client with severe depression includes using communication observations about the client's dress and environment, especially if the client is mute. The nurse also allows time for the client to respond and sits there even if the client won't respond. The nurse should ask about suicide plans and avoid trite reassurances such as "Everything will look better tomorrow," and "Everyone has bad days."

The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic?

"You haven't had an appetite at all?" Rationale: The therapeutic nursing communication technique is restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. Options 3 and 4 block the communication process. Option 1 focuses on the number of weeks that the lack of appetite has been present rather than the specific problem.

A client was diagnosed with acute pancreatitis 10 days ago. The nurse interprets that the episode of acute pancreatitis is fully resolved if the serum lipase level drops to which value?

135 units/L Rationale: The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for approximately 10 days after the onset of symptoms. This makes lipase a valuable test for monitoring the client's pancreatic function. The serum lipase level of 135 units/L indicates resolution of the acute pancreatitis because it is a normal value. The remaining options identify elevated lipase levels.

Dantrolene sodium (Dantrium) is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication?

Acts directly on the skeletal muscle to relieve spasticity Rationale: Dantrolene acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply

Eat a nutritious diet. Use a pressure relief pad Check the bottom sheet for wetness and wrinkles.

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and gloves

A client has been given a prescription for metoclopramide (Reglan) four times a day. Which is the optimal time to take this medication?

One hour after each meal and at bedtime Rationale: Metoclopramide is a gastrointestinal stimulant. The client should be taught to take this medication 30 minutes before meals and at bedtime

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?

Prolonged bed rest Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 8.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bedrest is hypocalcemia.

The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? Select all that apply.

Rationale: The gentamicin, theophylline, and carbamazepine levels are within the normal therapeutic range; all other results are abnormal (too high). Therapeutic medication levels include the following: gentamicin, 5 to 10 mcg/mL; tobramycin 5 to 10 mcg/mL; digoxin (Lanoxin), 0.5 to 2 ng/mL; phenytoin (Dilantin), 10 to 20 mcg/mL; theophylline, 10 to 20 mcg/mL; and carbamazepine (Tegretol), 5 to 12 mcg/mL.

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?

Scallops Rationale: Scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items identified in the remaining options have negligible purine content and may be consumed by the client with gout.

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Water pad The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client's weight on the device. These include foam, water, gel, or alternating air pads. A plastic-lined pad absorbs moisture but provides no pressure relief. A pillow provides cushion but does not redistribute weight equally. An air ring relieves pressure in some spots but causes pressure in others by its design.

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness?

"I can remove the harness to bathe my infant." Rationale: The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings

The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?

"The nizatidine (Axid) will cause me to produce less stomach acid." Rationale: Nizatidine, a histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine H2-receptor blockers decrease the secretion of gastric acid (HCL). Antacids are used as adjunct therapy and neutralize acid in the stomach. Omeprazole is a proton pump inhibitor. Sucralfate (Carafate) promotes healing by covering the ulcer, thus protecting it from erosion caused by gastric acids.

The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.

A high achiever Personality changes Lanugo over the back and extremities Rationale: Signs and symptoms of anorexia nervosa include being a high achiever, hypotension, dry skin, cold intolerance, and lanugo over the back and extremities. The client also experiences personality changes

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates an understanding of this disorder?

All 50 states require routine screening of all newborns for PKU." Rationale: PKU is an autosomal-recessive disorder. Treatment includes the dietary restriction of phenylalanine intake (not tyramine intake). PKU is a genetic disorder that results in central nervous system (CNS) damage from toxic levels of phenylalanine in the blood.

The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery would support this diagnosis?

Abdominal tenderness and chills Rationale: Symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications such as infections of the fallopian tubes, ovaries, and blood (sepsis).

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client. Rationale: A client with paranoia is distrustful and suspicious of others. Joking, laughing, or whispering in front of the client would increase these feelings in the client. Options 1, 2, and 4 are not appropriate or helpful interventions for the client with paranoia.

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse?

Apply a sterile dressing soaked with normal saline to the wound. Rationale: Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs as a complication 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The surgeon needs to be notified.

A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client?

Asking the client to pull up on a trapeze to lift the hips off the bed Rationale: If the client in skeletal traction may not turn from side to side, the nurse should have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bedpan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other.

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?

Baked turkey Rationale: Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?

Bleeding and swelling cause increased pressure in an area that cannot expand. Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia, which does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula Rationale: Perinatal transmission of HIV can occur during the antenatal period, during labor and birth, or in the postpartum period if the client is breast-feeding. This information will help the client choose a feeding method that will support parenting and the normal physiological development of her infant. Bottle-feeding represents the best choice when considering current knowledge of HIV transmission during pregnancy.

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

Crutches and the left leg, then advance the right leg Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg and then the unaffected leg is moved forward

The nurse should check for vision loss in a client with which condition?

Diabetes mellitus Rationale: Elevated blood glucose levels can cause temporary blurred vision. Over time, permanent retinal changes can occur in clients with diabetes mellitus.

The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply.

Dry skin Constipation Cold intolerance Rationale: Signs of hypothyroidism include dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesias; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter. Irritability, palpitations, and weight loss are signs of hyperthyroidism

Which food sources should the nurse include in the discharge teaching plan of a client with cobalamin (vitamin B12) deficiency anemia? Select all that apply.

Eggs Liver Red meats

The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen?

Have the client take three deep breaths Rationale: To obtain a sputum specimen, the client should brush his or her teeth to reduce mouth contamination. The client should then take three deep breaths and cough into a sputum specimen container. The client should be encouraged to cough and not spit so that sputum can be obtained. Sputum can be thinned by fluids or by a respiratory treatment, such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement." The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation: 8 to 12 glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.

A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process?

Myasthenia gravis Rationale: Myasthenia gravis can often be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of edrophonium. This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds to receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine (Prostigmin), also may be used because its effect lasts for 1 to 2 hours, providing a better analysis. For either medication, atropine sulfate should be available as the antidote.

A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

No rapid heartbeats or anxiety Rationale: Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.

An African-American client has been admitted for a skin rash on his lower back. Which should the nurse rely on when assessing the skin rash? Select all that apply.

Palpation Induration Rationale: The darker a person's skin, the more difficult it is to assess for changes in color. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation for warmth and induration rather than observation

The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the health care provider's (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure

Rationale: A pelvic sling is a traction device consisting of a hammock-like belt wherein the sling cradles the pelvis in its boundaries. It is used for the treatment of one or more pelvic fractures. Option 1 identifies a cervical halter skin traction. Option 2 identifies a pelvic belt traction. Option 4 identifies Russell's traction.

The prescription reads to infuse an insulin drip at 12 mL/hr. There are 100 units regular insulin in 250 mL of normal saline. How many units of insulin will the client receive per hour? Fill in the blank.

Rationale: Use ratio and proportion method of calculation. 100 units: 250 mL = x: 12 mL 250x = 1200 x = 4.8

A client having preadmission testing before surgery has blood drawn for the determination of serum electrolyte levels. The nurse determines that which result warrants a call to the health care provider by the nurse?

Sodium, 148 mEq/L Rationale: The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified is the serum sodium level.

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Stridor Rationale: The nurse reports the presence of stridor to the RN immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. A respiratory rate of 26 breaths per minute and congestion are abnormal, but additional data are needed to determine if these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?

Suction equipment Rationale: In a postoperative client, a concern related to initiating a diet is aspiration. Initiating postoperative oral fluids may lead to distention and vomiting. Suction equipment must be available. A blood pressure cuff may be necessary but is not the priority from the options provided. A code cart is unnecessary. A straw may help the client sip fluids but is not necessary.

A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication?

The client complains of a headache, and the blood pressure is elevated. Rationale: Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-threatening syndrome. It is a cluster of clinical symptoms that results when multiple spinal cord autonomic responses discharge simultaneously. Exaggerated autonomic nervous system reactions to stimuli result in sudden hypertensive episodes with severe headache. The client may sweat profusely above the level of the cord lesion and complain of a stuffy nose. The knee-jerk response is not affected. Pupils may be dilated. Although a distended bladder is often the precipitating event, it is not indicative of dysreflexia, and not all clients with bladder distention exhibit dysreflexia.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination?

The client may have perceptual and spatial disabilities Rationale: The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often result in interpretations that the client is less disabled than is the case. However, impulsive actions and confusion in carrying out activities may be very much a problem for these clients, as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visuospatial processing and awareness of body space. The left hemisphere is dominant for language abilities.

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma. Rationale: Short-term goals would include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal physical wounds that were inflicted at the time of the rape

The nurse is assisting in planning a teaching session with a client diagnosed with urethritis caused by infection with Chlamydia. The nurse should plan to include which point in the teaching session?

The most serious complication of this infection is sterility Rationale: The most serious complication of chlamydial infection is sterility. The infection can be prevented by the use of latex condoms. It may be treated with doxycycline or with azithromycin (Zithromax). All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

A urinary analgesic is prescribed for a client with a urinary tract infection. When should the nurse tell the client that it is best to take the medication?

With meals Rationale: A urinary antiseptic is administered with meals to decrease gastrointestinal side effects

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position?

With the head and chest at a 30-degree angle, with the neck slightly extended Rationale: The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Options 1, 2, and 3 do not achieve these goals.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position?

With the head of the bed elevated no more than 15 degrees Rationale: Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 4 to 6 hours. The client may turn from side to side. The head of the bed is not elevated more than 30 degrees to prevent kinking of the blood vessel at the groin and possible arterial occlusion.

A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate?

Withhold the dose and notify the registered nurse Rationale: Carteolol HCl is a beta-blocking agent that can constrict bronchial airways and cause narrowing if absorbed systemically. This can lead to bronchospasms. The nurse should notify the registered nurse because the client has pulmonary disease, and the condition may worsen with administration of a beta blocker. The medication would not be administered. The medication is not shaken vigorously. There is no reason to obtain a sample of eye drainage.

A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed?

p24 antigen assay Rationale: True HIV infection in the infant is confirmed by a p24 antigen assay, culture of HIV, or polymerase chain reaction (PCR). A Western blot confirms the presence of HIV antibodies. The CD4 count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action?

Confine the fire by closing the room door. : The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished.

The nurse, caring for a child with aplastic anemia, is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 cells/mm3 and a platelet count of 20,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities. Rationale: Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?

Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide. Rationale: A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other options are not appropriate initially.

A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicates that the client is experiencing a protein deficiency?

Transferrin, 90 mg/dL Rationale: Serum transferrin is an iron transport protein that can be measured directly or calculated as an indirect measurement of total iron-binding capacity. It is a more sensitive indicator of protein status than albumin. When the serum transferrin level is less than 100 mg/dL, the level of visceral protein depletion is severe.

The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?

Uric acid level Rationale: Busulfan (Myleran) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury

The nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine (Tegretol). The nurse determines that the client understands the use of the medication if the client knows to perform which activity

Use sunscreen when outside. Rationale: Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth (not excessive salivation), and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued because it could cause return of seizures or status epilepticus. Fever and sore throat (leukopenia) should be reported to the health care provider (HCP).

A client is being given a transcutaneous electrical nerve stimulation (TENS) unit to use for relief of chronic pain. Which instructions should the nurse reinforce to the client about the TENS unit? Select all that apply.

Using this unit will help relieve the pain. The unit works after attaching electrodes to the skin. The unit needs to be prescribed by the health care provider. The unit will decrease the amount of pain medication needed. The electrodes attached to the unit are placed on the skin around the area of pain. Rationale: The TENS unit is a portable system that relieves pain and reduces the need for analgesics. It is attached to the skin of the body around the area of pain by electrodes. It is not necessary that the client remain in the hospital for this treatment. However, this pain relief method needs to be prescribed by a health care provider.

The nurse is attempting to ensure the parent is able to safely administer at home the prescribed ear drops to the 2-year-old client. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used

Have the child lie on his or her back with the affected ear facing up. Massage the area anterior to the ear to facilitate entry of the drops. Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. Straighten the ear canal by pulling the pinna of the affected ear down and back. Slowly instill the number of drops prescribed by the health care provider into the ear Keep the child in the same position for 2 to 3 minutes.

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity is a part of the method to accurately determine the amount of flow for documentation purposes?

Weighing the perineal pad before and after use Rationale: The most accurate method for determining the amount of lochial flow is to weigh the perineal pads before and after use. Once these two weights are noted, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow, the time between pad changes is a factor that must also be incorporated into the analysis

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client makes which statement?

"It may be 2 years before I know if my baby has HIV." Rationale: Breast-feeding is contraindicated (depending on the health care provider's prescription) if the mother is positive for HIV because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertain that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV.

Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement?

"My peripheral vision will not be distorted." Rationale: Aphakia is the absence of the eye's lens and is corrected by prescriptive glasses, contact lenses, or an intraocular lens implanted surgically. Although glasses can be used for this disorder, they have several disadvantages. With the use of glasses, only central vision is corrected and peripheral vision is distorted. There is approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted. It is difficult for the client to judge distances, such as when driving a car.

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem?

"What have you been eating and drinking since the surgery?" Rationale: Constipation is marked by difficult or infrequent passage of stools that are hard and dry. Constipation has numerous causative factors, including psychogenic factors, lack of physical activity, inadequate intake of food and fiber, and medication influences. A client recovering from knee surgery may have several factors influencing elimination patterns. The question in option 4 will elicit data regarding the client's intake and will assist in determining whether an inadequate intake of food and fiber exists.

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?

A few individuals such as the board of directors Rationale: With regard to the decision-making process, organizations may be described as having a centralized or decentralized structure. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decision making involves a number of individuals and filters down to the individual employee, the organization is said to operate in a decentralized fashion.

The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed?

A mydriatic medication Rationale: A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. A miotic agent would constrict the pupil. An osmotic agent would act to decrease intraocular pressure. A thiazide diuretic would promote the excretion of body fluid. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

A client is to have an upper gastrointestinal (GI) series. Which nursing action should be done concerning the procedure?

Administer a laxative after the procedure because barium was administered. Rationale: Barium sulfate, which is used as contrast material during an upper GI series, is a constipating material. If it is not eliminated from the GI tract, it can cause obstruction. Therefore, laxatives or cathartics are administered as part of routine postprocedure care.

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply.

Age less than 32 years Practicing a religion Married over 10 years Rationale: Risk factors for suicide include being a male; men greater than age 45 and women greater than age 55; white males; those without religious affiliation; being divorced; being a professional; and having a physical illness that involves a loss of mobility, disfigurement, and chronic pain.

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon Rationale: Al-Anon is a support group for families of alcoholics. Fresh Start is a self-help group for those with addiction to nicotine. Families Anonymous is a support group for parents of children who abuse substances. Alcoholics Anonymous is a major self-help organization for those who suffer from alcoholism.

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving. Rationale: Unless the client is declared incompetent or dangerous, the nurse assists the client with problem solving (option 2). This action will engage the client in the plan of care in the hope that the continued conversation will delay the client's departure and shift thought processes to a plan for health and well-being and a functional life. A schizophrenic client is likely to have altered thought processes and thus have irrational plans or be unable to plan without assistance (option 1). The nurse avoids the promotion of security devices or blocking exits (options 3 and 4), which can be interpreted as false imprisonment or assault because, as client advocate, the nurse knows that a client has the right to self-determination.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?

Psychomotor retardation and side effects of medication Rationale: In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours as needed (PRN) for pain, is prescribed. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. What should the nurse determine about the medication dosage?

The dosage is within the safe range. Rationale: Convert pounds to kilograms by dividing by 2.2, because 1 kg = 2.2 pounds.Therefore, 110 lb ÷ 2.2 = 50 kg. Then determine the dosage parameters. Dosage parameters: 0.1 mg/kg × 50 kg = 5 mg 0.2 mg/kg × 50 kg = 10 mg The dosage is safe.

A client has a continuous catheter irrigation postoperatively after having a transurethral resection of the prostate. The nurse notes that fluid is entering the bladder, but none appears to be draining. In priority order, which actions should the nurse take?

Ask the client about bladder spasms and discomfort. Check the bladder for distention. Check to ensure drainage tubing is not kinked Ask the client about bladder spasms and discomfort. Check the bladder for distention. Review intake and output record. Rationale: A drainage tube that is kinked will not allow the bladder irrigation solution to exit the body and can be done quickly while observing the system setup. Assessing the bladder for distention would follow because a clot may be preventing drainage. Asking the client if there is any discomfort or spasms may indicate improper drainage. Reviewing the intake and output record would be last because the nurse can see that fluid is entering the system but not leaving.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

Butter Rationale: Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measure to reduce the risk of adverse effects from this medication?

Encourage coughing and deep breathing. Rationale: Morphine sulfate suppresses the respiratory and cough reflex. The client should be encouraged to cough and deep breathe in order to prevent atelectasis and subsequent pneumonia. Keeping the client in a supine position is harmful because it could lead to atelectasis. Monitoring the temperature will detect infection but not prevent it. Encouraging fluids will help liquefy secretions for coughing but will not prevent atelectasis unless coughing and deep breathing also are performed.

The nurse provides dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse tells the client that the fruit highest in potassium is which selection?

Kiwifruit Rationale: Foods that are high in potassium include bananas, cantaloupe, kiwifruit, and oranges. Fruits low in potassium include apples, cherries, grapefruit, peaches, pineapple, and cranberries.

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Stridor Rationale: The nurse reports the presence of stridor to the RN immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. A respiratory rate of 26 breaths per minute and congestion are abnormal, but additional data are needed to determine if these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time

The nurse is assisting in reinforcing a teaching plan for a client given a prescription for pioglitazone (Actos). The nurse plans to reinforce instructions to the client about which information related to this medication?

Signs of hypoglycemia Rationale: Pioglitazone is an antidiabetic medication used for clients with type 2 diabetes mellitus, and the medication reduces the blood glucose. It is used as monotherapy or in combination with a sulfonylurea, metformin (Glucophage), or insulin as an adjunct to diet and exercise. It should be taken 15 to 30 minutes before a meal. A prescribed diet is an essential component of treatment in a diabetic client, but the client is not told to increase calorie intake unless this is specifically prescribed by the health care provider. The client is instructed in the signs of hypoglycemia because this effect can occur with the use of antidiabetic medications. The client is also instructed regarding the interventions necessary if hypoglycemia occurs. Anemia is not associated with the use of this medication.

The nurse has just received report on a newly admitted client who is cognitively impaired and experiencing pain. Which data collection techniques should be included in this client's plan? Select all that apply.

Observe for grimacing. Listen for vocalizations. Observe facial expressions Use a numerical pain scale. Monitor for changes in behavior.

The nurse is employed in a mental health clinic that specifically manages somatization disorders. The nurse understands that which is a characteristic of a somatization disorder?

The client has multiple physical complaints. Rationale: A somatization disorder is characterized by multiple physical complaints involving numerous body systems; the cause of the complaints is presumed to be psychological. A compulsion is the performance of rituals or repetitive behavior designed to prevent some event, divert unacceptable thoughts, and decrease anxiety. A dissociative disorder is characterized by a disruption in integrative functions of memory, consciousness, or identity. With an obsession, the client is preoccupied with persistently intrusive thoughts and ideas.

The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.

The client's temperature The date the specimen was drawn The time the specimen was drawn Any supplemental oxygen the client is receiving Rationale: An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the specimen was drawn with the client using room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. A list of the client's allergies is not a necessary piece of information required for analysis of the specimen.

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply.

Tinnitus Ototoxicity Nephrotoxicity Hypomagnesemia Rationale: Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase-nonspecific medications that affect the synthesis of DNA by causing the cross-linking of DNA to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity.

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.

Rationale: To obtain a residual urine, it is necessary for the client to void, then obtain a bladder scan. If less than 100 mL of urine is viewed on the scan, continuing to monitor as prescribed is appropriate. Obtaining the scan before voiding would tell the nurse how much fluid the bladder can hold. Decreasing fluids may lead to dehydration and will not affect residual urine. Notifying the health care provider of normal findings is inappropriate, as is catheterizing for 100 mL of residual urine.

The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination?

Red, dull, thick, and immobile tympanic membrane Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. The remaining options are not findings that would be noted in an otoscopic examination in the client with mastoiditis.

A 17-year-old pregnant client is being seen at the obstetric clinic. The nurse is reviewing the following laboratory results, which were obtained 2 hours after breakfast: hemoglobin 10.5 g/dL, sodium 140 mEq, glucose 120 mg/dL, potassium 4.1 mEq. Which dietary instruction should the nurse reinforce for this client?

Increase the amount of red meats. Rationale: This client's hemoglobin level is low; red meats are a good source of iron. The glucose level is within range of nonfasting samples. Based on the laboratory results, there is no reason for the client to increase the milk intake or limit the number of bananas consumed daily.

A client is being treated for heart failure and is receiving digoxin (Lanoxin). The client's vital signs are blood pressure 85/50 mm Hg, pulse 96 beats per minute, respirations 26 breaths per minute. To evaluate therapeutic effectiveness of this medication, the nurse should expect which change in the client's vital signs?

Blood pressure 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute Rationale: The main function of digoxin is inotropic. The increased myocardial contractility is associated with increased cardiac output causing a rise in the blood pressure in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of heart rate

The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.

Rationale: Intradermal injections are most commonly given in the inner aspect of the forearm away from heavy pigmentation that would make visualizing the site for possible reactions difficult. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. There are no criteria involving peripheral vessels.

The nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which first?

Remove the IV. Rationale: Blanching, coolness, and edema of the IV site are all classic signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the first action by the nurse is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should be done only after the IV has been removed so that tissue damage is thoroughly assessed.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that the client needs further teaching when the client states that he should perform which action?

Reset the degrees of flexion or extension according to comfort. Rationale: The client is instructed to stop and start the continuous passive motion device and leave the padding in the device for leg protection. The client should be taught proper positioning and alignment. The client should not try to adjust the flexion and extension settings. These are decided on by the orthopedic surgeon and are maintained as prescribed.

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address the client's need for which?

Safety and security Rationale: An important consideration when working with clients who have delusions is the maintenance of safety. Delusions may compel a client to take risks. Because the client shows no evidence of dehydration and malnutrition at this time, safety and security are the priority needs. Psychosocial needs (options 1 and 4) are not immediate client needs

Trimethoprim-sulfamethoxazole (TMP-SMZ) is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy?

Sore throat Rationale: Clients taking trimethoprim-sulfamethoxazole (TMP-SMZ) should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the health care provider (HCP) if these symptoms occur

The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?

"I should not wear deodorant on the day of the test." Rationale: Mammography takes about 15 to 30 minutes to complete. Some discomfort may be experienced because of the breast compression required to obtain a clear image. Maintaining a nothing-by-mouth (NPO) status before the procedure is not necessary. A sports bra is not required; the test is performed without clothing. Deodorants, powders, and lotions should not be worn on the day of the test because it will affect the testing process and affect the imaging of the breasts.

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

Notify the registered nurse. Rationale: Sanguineous drainage is bright red and indicates active bleeding. If active bleeding is present, the registered nurse should be notified. Covering the wound and reassessing in 1 hour will delay needed intervention. Leaving a wound open to air can lead to infection.

The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications

Tap water Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts.

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the health care provider will be contacted regarding discharge. Rationale: False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital, if the client was voluntarily admitted, and if there are no agency or legal policies for detaining the client. The nurse should not allow the client to leave without first contacting the health care provider. An attempt to persuade the client to stay or contacting security may arouse violent feelings in the client. It is not appropriate to restrain the client.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis?

Red-brown urine Rationale: Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, and hypertension is also common. A mid- to high urinary specific gravity is associated with glomerulonephritis. BUN levels may be elevated.

A client has been prescribed allopurinol (Zyloprim). The nurse reinforces which information concerning the administration of the medication?

Drink at least eight glasses of fluid every day. Rationale: Clients taking allopurinol are encouraged to drink 2000 to 3000 mL of fluid a day to prevent the formation of crystals in the urine. Allopurinol is to be given with or immediately following meals or milk. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, the health care provider should be notified because this may indicate hypersensitivity.

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which symptoms or behaviors as requiring immediate intervention?

Constant physical activity and poor oral intake Rationale: Mania is a period when the mood is predominantly elevated, expansive, or irritable. The client's mood may be characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Each of the options is reflective of possible symptoms of mania. However, option 1 clearly identifies the priority, a physiological need.

The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?

Obtain a blood glucose reading Rationale: The signs of hypoglycemia and hyperglycemia may be difficult to distinguish. Weakness, headache, and blurred vision can occur in either blood glucose alteration. A blood glucose reading will assist in confirming the diagnosis so that the appropriate action can be taken. Option 3 would be implemented if the child had hypoglycemia. Option 4 is inappropriate because the child should eat meals at basically the same time each day to achieve the best diabetic control. Contacting the health care provider would not be the immediate action; however, the nurse should inform the registered nurse of the situation.

Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse tells the client that which is the best time to take the insulin?

Once daily, at the same time each day Rationale: Insulin glargine is a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has 24-hour duration of action and is administered once a day, at the same time each day.

A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which side/adverse effects of the medication? Select all that apply.

Rash Hepatotoxicity Nevirapine (Viramune) is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels. Hyperglycemia, peripheral neuropathy, and reduced bone density are not side/adverse effects of this medication.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out Rationale: With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell, forcing intracellular potassium out.

A client is scheduled for an oral cholecystography. The nurse should plan to obtain what type of diet for the evening meal before the test?

Fat-free Rationale: Normal dietary intake of fat should be maintained during the days preceding the test in order to empty bile from the gallbladder. A fat-free diet is prescribed on the evening before the test. The fat-free supper prevents contraction of the gallbladder and allows accumulation of the contrast substance needed for x-ray visualization. Options 1, 3, and 4 are incorrect.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea Rationale: Opioids are central nervous system (CNS) depressants. Option 1 identifies some of the signs/symptoms associated with withdrawal from opioids

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

I need to avoid sun exposure before 10:00 am and after 4:00 am."

The nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching?

Our child sleeps in our bedroom at night Rationale: Parents are especially concerned about seizures that might go undetected at night. The nurse should suggest a baby monitor. Reassurance by the nurse should ensure parental confidence and decrease parental overprotection. Option 2 is a common concern. Options 3 and 4 demonstrate the parents' ability to choose respite care and activities appropriately. The parents need to be reminded that as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care is appropriate to minimize complications.

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?

Phlebitis of the vein Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions.

The nurse has given a client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence immediately?

Problems with visual acuity Rationale: Ethambutol (Myambutol) causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Red-orange discoloration of secretions occurs with rifampin (Rifadin).

The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition?

Human immunodeficiency virus (HIV) infection Rationale: Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and is used for prophylaxis in health care workers at risk of acquiring HIV after occupational exposure to the virus

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform?

Inform the client that she is being secluded to help regain control of herself. Rationale: The client needs to be removed to a nonstimulating environment because of the client's behavior. Options 2, 3, and 4 are nontherapeutic. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.