HESI PN Fundamentals

A woman in the clinic is at 32 weeks gestation and has the diagnosis of pregnancy induced hypertension (PIH). You are the PN who is to perform client instruction. Which of the following statements, made by the client, indicates to the nurse that further instruction is required? "If I lie in bed on my left side, it will probably cause increased urination." "I should be sure to maintain a diet that has a good amount of protein." "I will have to keep my room darkened and not watch much television." "If the bed rest works, I may lose a pound or two in the next few days."

"I will have to keep my room darkened and not watch much television." PIH (preeclampsia, toxemia) is an increase of systolic blood pressure of 30 mmHg or 15mm Hg of diastolic increase with proteinuria and/or edema after 20 weeks gestation. Watching television could be helpful to reduce blood pressure. Lying on the left side promotes good perfusion of blood to the uterus and decreases the blood pressure. Replacing protein lost in the urine increases plasma colloid osmotic pressure through diet is good advice. Bed rest will result in reduction of retained fluids.

A 21-year-old female thinks she is pregnant. At the doctor's office, the client asks the nurse, "How reliable is the drugstore pregnancy test." Which of the following identifies the nurse's best response? "The tests are quite reliable. In order to be sure you are pregnant, I need to get some more information from you." "The test are less reliable than the one the doctor does. We will have to repeat it." "Those kits are not very reliable. Your doctor should make the diagnosis." "They are very reliable. You can be sure you are pregnant."

"The tests are quite reliable. In order to be sure you are pregnant, I need to get some more information from you." Pregnancy tests are based on the presence of HCG (human chorionic gonadotropin), which is secreted during pregnancy. Physician tests use the same principle as the store bought test in determining if a female is pregnant or not pregnant. Additionally, during an office visit, the nurse should take a history to confirm the results of the tests. The physician will examine the woman to help confirm the test results.

The nurse understands an infant's posterior fontanel closes within what time period? 1 - 2 months 2 - 3 months 6 - 12 months 12 - 18 months

1 - 2 months The posterior fontanel closes between 1 and 2 months in an infant. The nurse is able to palpate the anterior fontanel up until the child reaches 18 months of age.

normal adult respiratory rate

14-20 respiration per minutes

A patient who is almost 39 weeks pregnant comes to your office with uterine contractions that are mild and infrequent. The doctor orders a sonogram to determine the amniotic fluid index (AFI). Which of the following results would cause concern? 4.5 6.0 7.5 10.5

4.5 The normal range for AFI for a term pregnancy is greater than 5 cm and less than 25 cm. All of the results in the choices fall within this range except the 4.5 result. Amniotic fluid levels that do not fall into the 5 - 25 cm range are outside of normal limits.

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

A. Acknowledge that she is supporting the arm correctly. The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe

A. Assist the ambulating client back to the bed. An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D).

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.

A. Avoid any types of sprays, powders, and perfumes. The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high.

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

A. Be sure to have a complete physical examination before beginning your planned exercise program. The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A).

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

A. Chocolate pudding. The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding.

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.

A. Commend the client for selecting a high biologic value protein. Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

A. Determine the etiology of the problem. Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

A. Give an around-the-clock schedule for administration of analgesics. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D).

An African American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension

A. Inquire about the source and type of pain. Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain).

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.

A. It is important that you continue your medication while learning to meditate. The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

A. Loosen the right wrist restraint. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints).

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.

A. Observe the appearance of the skin under the ice pack. The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

A. The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D).

When caring for a client with venous thrombosis, the nurse understands that the most accurate diagnostic test for venous thrombosis is what?

Ascending contrast venography The ascending contrast venography uses a contrast medium to assess the location of the venous thrombosis and the extent of the thrombosis. This test is considered the most accurate tool in diagnosing venous thrombosis.

A patient comes into the office and is diagnosed with a urinary tract infection. She has had several urinary tract infections over the last couple of years. You go over a teaching plan for her in hopes of preventing further urinary tract infections. Which of the following pieces of advice would NOT be included in your teaching plan? Fluid intake should be at least 3L/day. Void every 2 to 3 hours during the day. Avoid wearing cotton undergarments. Take prescribed medications.

Avoid wearing cotton undergarments. For a person who has frequent urinary tract infections, wearing cotton undergarments and loose clothing is recommended. All of the other choices are valid teaching points. Other teaching points are to shower rather than bathe, cleanse from the front to the back after toileting, void immediately after intercourse, and practice good hand washing technique.

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.

B. 8 a.m., 4 p.m., and midnight. Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best broncho-dilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

B. A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

B. A lactating woman nursing her 3-day-old infant. A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

B. Blood transfusions are forbidden. Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B).

The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

B. Continue asking the mother questions about the child. Eye contact is a culturally influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.

B. During the inhalation. The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D) and should deliver no more than two inhalations at a time (C).

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.

B. Flush the tube with water. The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

B. Fowler's. The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

B. Initiate an alternate site for the IV infusion of the medication. A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has anti-inflammatory actions, (D) is not indicated.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D).

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

B. Measure the pulse volume and capillary refill distal to the infiltration. Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D).

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

B. Note which actions were not implemented. First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

B. Nutritional history. Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks, you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

B. Place a pillow between your knees while lying in bed to prevent hip dislocation. The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy.

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

B. Reassess the client's blood pressure using a larger cuff. The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B).

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

B. Reposition the client on her side. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the: A. Arms. B. Upper torso. C. Head. D. Feet.

B. Upper torso. The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer.

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?

B. What vitamin and mineral supplements do you take? Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference.

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly: A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.

B. often follows relocation to new surroundings. Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.

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

C. Acknowledge the client's distress and tell her it is all right to cry. Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

C. Degree of flexion and extension of the client's knee joint. The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

C. Examining a chest x-ray obtained after the tubing was inserted. Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement.

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

C. Frontal lobe. The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of sensory and motor functions.

The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low-density lipoproteins needs to increase.

C. I will limit my intake of beef to 4 ounces per week. Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low-density lipoproteins (D) need to decrease rather than increase.

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

C. Infuse 10 percent dextrose and water at 54 ml/hr. TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. (C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem.

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

C. Keep gloved hands above the elbows. Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

C. Many complimentary healing practices can be used in conjunction with conventional practices. Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.

C. Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

C. Reposition in a Sim's position with the client's weight on the anterior ilium. The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned.

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

C. Skim milk, turkey salad, roll, and vanilla ice cream. Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium.

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

C. The nurse who transferred the client to the chair when the fall occurred. The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed, and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D).

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client: A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.

C. demonstrates the wound care procedure correctly. A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care.

The nurse asks the newly pregnant woman if she has a cat as a pet. Which of the following reasons best explains why the nurse asks about pets? Cats may suffocate new babies and should not be in the home when a baby arrives. Cat feces may cause toxoplasmosis, which can lead to blindness, brain defects, and stillbirth. Cats are jealous of babies and may try to kill them during infancy. If the mother gets scratched by a cat, the baby may develop heart defects.

Cat feces may cause toxoplasmosis, which can lead to blindness, brain defects, and stillbirth. Cats may become infected with toxoplasmosis, which if ingested by the mother can cause toxoplasmosis and can lead to neurological lesions, causing blindness, brain defects, and death. Parents should be alert for safety with any pet, but cats do not suffocate new babies or try to kill them. It is not being scratched by a cat that is the biggest danger during pregnancy; it is the possibility of developing toxoplasmosis from the feces.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

D. Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

D. Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of a urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

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

D. Ensure the accuracy of the blood type match. All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

D. Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.

D. Hot remedies restore balance after surgery, which is considered a "cold" condition. Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed and stand the client on the right foot.

D. Move the chair parallel to the right side of the bed and stand the client on the right foot. (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.

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

D. Notify the healthcare provider of the family's request. The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

D. Re-oxygenate the client before attempting to suction again. Suctioning should not be continued for longer than ten to fifteen seconds since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

D. Request and document the name of the certified translator. A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

D. The body's receptors adapt over time as they are exposed to heat. (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

D. Upper arm circumference. Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.

The type of female pelvis that is considered the ideal pelvis for a vaginal birth is which of the following? A. anthropoid B. android C. platypelloid D. gynecoid

D. gynecoid The gynecoid pelvis is considered the "true" female pelvis. It is considered the ideal pelvis for a vaginal birth.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.

D. is disoriented to place and time. The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B) and does not demonstrate a diminished attention span (C).

A nurse is instructing students about seizures in pediatric patients. He explains that seizures are categorized as generalized or partial and explains each. In talking about how to react when a child has a seizure which of the following statements would be included? Restrain the child as soon as possible. Turn child on stomach to prevent injury. Quickly get help to restrain the child. Do not use a tongue blade during a seizure.

Do not use a tongue blade during a seizure. If a child is having a seizure you would not restrain him nor would you get anyone else to help you restrain him. You would do just the opposite. Also, you would turn him on his side to maintain his airway during the seizure; you would not turn the child on his stomach. The only statement that is correct is that you should not use a tongue blade, padded or not, during a seizure because it can cause traumatic damage to the patient's oral cavity.

If you are combing the hair of a patient who is unable to do so, you would know all of the following EXCEPT: If hair is tangled, use 95% alcohol for dry hair. Start at the ends, working toward the scalp. Hold hair close to head to prevent pulling. Use mineral oil for oily hair to untangle. Comb or brush the hair daily to avoid tangles.

If hair is tangled, use 95% alcohol for dry hair. Use mineral oil for oily hair to untangle. For tangles, you would use 95% alcohol for oily hair. You would use mineral oil for dry hair. Shampoo as often as necessary and as patient's condition permits.

Which of the following is not generally associated with aging? Chronic health problems Increased appetite Skin breakdown Reduction in muscle mass

Increased appetite Generally, as people age, appetite will decrease, not increase. However, A, C, and D will often occur during the aging process.

Distributing HIV brochures and holding a presentation at a health fair is an example of which of the following? Information dissemination Health risk appraisal and wellness assessment Lifestyle and behavior change Environmental control program

Information dissemination Knowledge is very important in controlling environmental issues. The best way to do this is through the public circulation and dispersement of information.

The community center nurse who does health education is conducting what level of prevention? Primary prevention Secondary prevention Tertiary prevention Focused prevention

Primary prevention Primary prevention includes health promotion and requires action on the part of all to prevent disease from occurring. It is the nurse's responsibility to provide information and it is the patient's responsibility to utilize the given information.

Which of the following tests is used to identify the presence of the sickle cell trait?

The hemoglobin electrophoresis test is used in women of African or Mediterranean descent to identify the presence of the sickle cell trait. Sickle cell anemia is an autosomal disease occurring mainly in African Americans and occasionally in Caucasians of Mediterranean descent. It causes breakdown of red blood cells.

There are a number of sociological theories that have been put forth about the aging process. Which of the following is NOT a part of the theory of disengagement? The person remains active and interacts with society and its events. It supports leisure as a form of activity. Lifelong coping strategies continue. There is a mutual withdrawal from social interaction by older adult and society.

The person remains active and interacts with society and its events. Lifelong coping strategies continue. These are not part of the theory of disengagement. This theory is controversial. It describes engagement as active occupation and devotion and respects individually-initiated withdrawal.

A nurse who is preparing a patient for eye surgery takes his intraocular pressure. She finds that the pressure in the right eye is 12 mm Hg and the pressure in the left eye is 17 mm Hg. The nurse would tell the patient that: The pressure in the right eye is low, but the pressure in the left eye is normal. The pressure in both eyes is high. The pressure in both eyes is normal. The pressure in the right eye is normal, but the pressure in the left eye is high.

The pressure in both eyes is normal. In this patient's case the pressure is normal in both eyes. Normal intraocular pressure ranges from 8 mm Hg to 21 mm Hg.

Your patient has had hip replacement surgery. She is being discharged and along with other instructions you advise her not to lift her leg upward from a lying position or elevate the knee when sitting. The primary reason for this is which of the following? This type of action may cause extreme pain. This type of action will delay healing. This type of action may cause venous thrombosis. This type of action may pop the prosthesis out of the socket.

This type of action may pop the prosthesis out of the socket. This question asks for the primary reason for this advice. The primary reason is that this type of action may pop the prosthesis out of the socket.

A PN in the postoperative department has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? temperature of 37.6° C (99.6° F) blood pressure of 100/70 mm Hg serous drainage on the surgical dressing urinary output of 20 mL/hr

Urinary output of 20 mL/hr A lesser output for 2 consecutive hours would indicate renal insufficiency and should be reported to the physician. A temperature higher than 37.7° C (100.0° F) or lower than 36.1° C (97° F) and a falling blood pressure are immediate concerns and should be reported. Light to moderate serous drainage at a surgical site is expected and should not be reported.

cerebral laceration

a break in the continuity of brain tissue.

Which toy would be most appropriate for a 4-year-old? a bicycle a puzzle with large pieces a pull toy a computer game

a puzzle with large pieces. At age 4, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5 or 6 year old child, a pull toy for a toddler and a computer game for a school age child.

The nurse is assessing a 2-month-old infant. The infant is quiet and is drifting off to sleep. Which of the following should the nurse perform first during the assessment? an examination of the ear asculate the lungs assess the infant'/s blood pressure palpate the head

asculate the lungs asculate the lungs. The best time to asculate the lungs, heart and abdomen of an infant is while the infant is asleep or quiet. During this time, the muscles, such as in the abdomen, are relaxed.

Types of microorganisms include:

bacteria, viruses, fungi, protozoa, and rickettsia.

Extrinsic motivation

behavior motivated by the desire to gain a reward or avoid a negative outcome

Sudden onset mutism with bizarre mannerisms and remaining in a stereotyped position with waxy flexibility is a presentation of which of the following types of schizophrenia? disorganized schizophrenia paranoid schizophrenia catatonic schizophrenia undifferentiated schizophrenia

catatonic schizophrenia Catatonic schizophrenia presents as a sudden onset of mutism, bizarre mannerisms, remaining in a stereotyped position with waxy flexibility. The patient may have dangerous periods of agitation and explosivity.

A pregnant woman who is having true rather than false contractions will experience all of the following EXCEPT: contractions that lessen with activity or rest discomfort that radiates from the back around to the abdomen contractions that are regular with increasing frequency cervix that is progressively effaced and dilated

contractions that lessen with activity or rest This is a sign of false labor rather than true labor. In true labor the contractions do not decrease with rest.

A client is scheduled for a dilation and curettage. The nurse instructs the client to come in a day before the scheduled procedure for the insertion of laminaria. The main reason for the laminaria insertion is to: prevent hemorrhaging dilate the cervix promote wound healing promote vaginal blood circulation

dilate the cervix Laminaria is a substance that is inserted into the canal of the uterus and is used to dilate the cervix. Also, the laminaria is used to absorb any moisture and secretions from the cervix.

Which of the following would NOT be related to fluid excess in a patient? edema dry skin poor skin turgor increased urine output

dry skin poor skin turgor increased urine output These are things related to fluid deficit rather than fluid excess. Fluid excess is associated with heart and kidney disease. It is observed as edema, weight gain, and reduced urine output.

Which of the following would indicate that a person is in a pre-diabetic stage? fasting blood glucose is 150 mg/dL fasting blood glucose is 110 mg/dL postprandial blood glucose is 110 mg/dL postprandial blood glucose is 130 mg/dL fasting blood glucose is 118 mg/dL

fasting blood glucose is 110 mg/dL fasting blood glucose is 118 mg/dL Prediabetes can occur when the fasting blood glucose is greater than 100 mg/dL and less than 126 mg/dL or when postprandial blood glucose is greater than 140 mg/dL and less than 200 mg/dL. Fasting blood glucose levels of 110 mg/dL and 118 mg/dL are therefore pre-diabetic.

The professional nurse caring for children with increased intracranial pressure is aware that which of the following is NOT personality and behavior signs of this condition? diminished physical activity and motor performance hallucinations and delusions increased sleeping and drowsiness irritability and restlessness

hallucinations and delusions The behavior signs include inability to follow simple commands, decline in school performance, lethargy, indifference, and the answers (a, c, and d). Hallucinations and delusions are not included in the list.

When assessing a patient for alcohol intoxication, all of the following would be supportive of this potential diagnosis EXCEPT: slurred speech heightened reflexes possible hypoglycemia mania decreased respiration

heightened reflexes mania decreased respiration These are not the usual signs of alcohol intoxication. Instead, reflexes are diminished; depression may be evident; and respiration is increased. Besides the other choices, signs include: drowsiness, tremors, impaired thinking; memory loss; nystagmus; nausea and vomiting; belligerence or grandiosity; and loss of inhibitions.

A female client is discharged from the hospital post delivery. The nurse escorts a mother and her newborn to the car. Which of the following approaches should the nurse instruct the new mother to place the newborn? in the mother's lap with the seat beat across both the mother and the baby on the front passenger side with the car seat facing forward in the back seat of the car with the car seat facing backwards in the middle section of the backseat with the baby positioned in the car seat facing forward

in the back seat of the car with the car seat facing backwards. While regulations may vary from state to state, it is recommended that an infant up to 1 year of age use a rear facing car seat or longer until they outgrow it.

At three hours after the birth of a newborn, the nurse should expect which of the following for the infant's respirations?

irregular and between 30 to 60 per minute Vital signs that are assessed within the first 4 hours of an neonate's birth should include blood pressure as needed, temperature, respirations and pulse, which is monitored every hour for the first four hours unless there is distress that warrants more frequent monitoring. The respirations for a newborn is between 30 to 60 per minute and they are irregular.

A 50 year old client has abdominal pain in the lower quadrant of the abdomen. The client's WBC shows 30,000/mm3. The nurse understands the WBC count: is within the normal range indicates a metabolic disorder is elevated and may indicate inflammation is consistent with metabolic distress

is elevated and may indicate inflammation The normal range for the white blood cell count (WBC) is between 4,300 to 10,800mm3. The client has a WBC of 30,000/mm3 which is outside of the normal range and is elevated. With some disorders such as appendicitis, which is an inflammatory disease, the WBC count is elevated.

A client who has a menstrual period more than 35 days a part correlates with which of the following conditions: hypomenorrhea menorrhagia metrorrhagia oligomenorrhea

oligomenorrhea. Irregular menstrual cycles include hypomenorrhea, menorrhagia, metrorrhagia and oligmenorrhea. With hypomenorrhea, the female's menstrual flow lasts a short period of time and the blood flow is light. When a client has bleeding between their menstrual cycle, this is called metrorrhagia. Menorrhagia is a heavy flow that lasts more than 7 days. Further, oligomenorrhea occurs when the client's menstrual flow happens more than 35 days a part. For example, a 17 year old has a menstrual period in July but does not have another menstrual period until September or October. The menstrual cycle typically occurs within a 28 day cycle.

Phases of separation anxiety

protest, despair, denial

Which of the following is NOT a therapeutic communication technique? broad openings refraction informing deflection

refraction deflection These are not therapeutic communication techniques. In addition to the other two choices, therapeutic communication techniques include: listening, restating, clarification, reflection, humor, focusing, sharing perceptions, theme identification, suggesting, and silence.

One minute after birth, the physician rates a newborn infant on five factors. Which of the following is not one of those factors? appearance pulse temperature grimace

temperature The physician will rate a baby one minute after birth on five factors. These factors are: appearance (color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone) and respiration (respiratory effort). This is called the APGAR score. The value of each factor is from 0 to 2. A score of 10 is optimum. Temperature is not one of the factors.

You have a patient who came into the emergency room in great emotional distress saying that she cannot stand to feel the way she does anymore. She says she doesn't sleep well, can't eat, feels hopeless and does not want to go on like this anymore. You know that this patient is in crisis and you also know that after determining that she is not at risk for injury the primary goal in her care is which of the following? to see that she is provided with the proper medication to get her into a self-help group to encourage her to exercise more to get the patient back to a pre-crisis level of functioning

to get the patient back to a pre-crisis level of functioning Although all of the choices are ones that are good for the patient, the primary goal in her care is to return her to her pre-crisis level of functioning. All of the other choices working in concert with each other may be a part of accomplishing this but on their own they are not the primary or initial goal.