HESI PRACTICE

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? a. Left hand b. Right hand c. Stronger hand d. Dominant hand

A! A cane should be used on the unaffected side. Weight-bearing can be shared by a cane and an affected leg when they are advanced forward together. Teaching with the right hand promotes leaning toward the affected side and does not permit sharing of weight by the stronger left side of the body. Teaching with the stronger hand is unsafe; the stronger hand may not be the left hand. Teaching with the dominant hand is unsafe; the dominant hand may not be the left hand.

Which clinical indicators identified by the nurse support the probable presence of a fecal impaction in a client? Select all that apply. a. Abdominal cramps b. Fecal liquid seepage c. Hyperactive bowel sounds d. Bright red blood in the stool e. Decreased number of bowel movements

A, B, & C! Peristalsis increases in an attempt to evacuate the hardened feces; spasms of the intestine may occur. When the bowel is impacted with hardened feces, there often is seepage of liquid feces around the obstruction and thus uncontrolled diarrhea. Intestinal gas builds up behind the obstruction; peristaltic waves initiate movement of intestinal contents that cause gurgling sounds in the intestine (borborygmi). Bright red blood in the stool is indicative of lower gastrointestinal (GI) bleeding. There are often frequent liquid bowel movements in the presence of an impaction.

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.

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). Correct Answer: B

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.

(C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct Answer: C

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D

A client with terminal cancer is to receive 2 mg of hydromorphone (Dilaudid) IV every 4 hours as needed for severe breakthrough pain. The vial contains10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. ___ mL

0.2 mL

A primary care provider prescribes cefazolin (Kefzol) 125 mg intramuscularly (IM) for a client. The vial contains 0.5 gm of cefazolin in powdered form. The instructions indicate to add 2 mL of sterile water to provide a solution that contains 225 mg per mL. Record your answer using one decimal place, including leading zero if applicable. ___ mL

0.6 Use the "Desire over Have" formula of ratio and proportion to solve this problem. Desire 125 mg = x mL Have 225 mg 1 mL 225x = 125 X = 125 ÷ 225 X = 0.55 mL. Round the answer up to 0.6 mL

A client is to receive 0.25 mg of digoxin intramuscularly. The ampule is labeled 0.5 mg = 2 mL. How many mL should the nurse administer? Record your answer using a whole number. ___ mL

1 The correct dose is 1 mL. Use ratio and proportion to solve the problem.

A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk. 1. 78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory 2. 70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound 3. 62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 4. 25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory

1. 70-year-old male, admitted with metastatic bone cancer, weighing 80 lbs, dehydrated, and bed bound 2. 62-year-old female, admitted because of a brain attack (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 3. 25-year-old male, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory 4. 78-year-old female, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory Risk factors for pressure ulcers include inadequate nutrition, dehydration, pain, decreased subcutaneous fat, and confinement to bed, making the 70-year-old male at greatest risk. An inability to sense or move the left side will inhibit changing positions without assistance, making the 62-year-old female post CVA next at risk. Urine and fecal incontinence may result in skin breakdown in the perineal and sacral areas. The 25-year-old male client is at some risk by not being able to communicate verbally and having urinary incontinence. The client's nutritional status is acceptable and client is able to move. The 78-year-old female client has minimal risk factors. Because she is scheduled for a knee replacement, which is an elective procedure, it can be assumed that her general health is within acceptable limits. Also, she is continent and ambulatory.

A nurse is planning to transfer a client who is experiencing pain when transferring from the bed to a chair. Place the following steps in the order in which they should be implemented. Incorrect 1. Explain the steps of the transfer. Incorrect 2. Verify the client's activity prescription. Incorrect 3. Ensure that the wheels on the bed are locked. Incorrect 4. Position the client in functional body alignment before transferring. Incorrect 5. Identify factors that may impact the ability to transfer.

1. Verify the client's activity prescription. 2. Identify factors that may impact the ability to transfer. 3. Explain the steps of the transfer. 4. Ensure that the wheels on the bed are locked. 5. Position the client in functional body alignment before transferring. Before transferring a client from the bed to a chair, the nurse needs to ensure that there is a prescription for "out of bed to a chair." Before explaining the transfer, the nurse must assess the stressors that may impact on the client's ability to participate in the transfer. Before the transfer the client should be informed about what is to be done and why. Locked wheels ensure that the bed will not move during the transfer; this ensures the safety of the client and nurse. Before transferring the client, the nurse should position the client in functional alignment to reduce any undue stress on muscles, joints, tendons, or ligaments during the transfer procedure.

A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. 1. Instill the prescribed solution. 2. Wash the hands. 3. Document the client's response to the procedure. 4. Aspirate the contents of the stomach. 5. Verify the solution to be administered.

1. Wash the hands. 2. Verify the solution to be administered. 3.Aspirate the contents of the stomach. 4.Instill the prescribed solution. 5. Document the client's response to the procedure. The hands should be washed to prevent contamination of the formula and the delivery system. Because numerous formulas may be used to correct specific nutritional problems, the nurse should verify that the formula to be administered is the one prescribed. The stomach contents should be aspirated to observe the fluid removed and to ascertain the feeding tube's location in the stomach. If the tube is correctly positioned, the solution is administered. The amount of formula given, the length of time involved, and the client's response to the procedure are recorded.

The primary health care provider instructs the nurse to administer a high dose of acyclovir (Zovirax) 60 mg/kg/day to a neonate with a body weight of 4.4 lbs. What dose does the nurse administer to the neonate each day? Record your answer in milligrams using a whole number. _______ mg

120 Acyclovir is used to treat herpes virus infection in a neonate. A high dose of 60 mg/kg/day of acyclovir reduces the mortality rate in children. The neonate has a birth weight of 4.4 lbs or 2 kg [2.2 lbs = 1 kg]; therefore, the nurse should administer 2 × 60 = 120 mg of acyclovir per day to the neonate

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number.

2! First convert 0.22 g to its equivalent in mg by multiplying by 1000 (move the decimal 3 places to the right). Use the "Desire over Have" formula of ratio and proportion to solve this problem.

A nurse is caring for a client after a total knee replacement who is requesting Vicodin in addition to the patient-controlled analgesia (PCA). The client reports having taken two Vicodin tablets every 4 hours for several weeks before surgery. If each tablet contains 500 mg of acetaminophen, how much acetaminophen had the client been ingesting per day? Record your answer using a whole number. ___ mg

6000 mg Two tablets every 4 hours over 24 hours equals a total of 12 tablets daily. Because each tablet has 500 mg, then 500 × 12 = 6000 mg. This is more than the recommended maximum dose of 4000 mg/24 hr for short-term use.

Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. a. Encouraging regular dental checkups b. Facilitating smoking cessation programs c. Administering influenza vaccines to older adults d. Teaching the procedure for breast self-examination e. Referring clients with a chronic illness to a support group

A & D! Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

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.

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 antiinflammatory actions, (D) is not indicated. Correct Answer: B

A nurse administers the first series of immunizations to a 2-month-old infant. The nurse tells the mother that if the site becomes inflamed she should give the prescribed acetaminophen (Tylenol). What else should the nurse instruct the mother to do? a. Place a warm compress on the area. b. Put a witch hazel compress on the site. c. Give a cool sponge bath for 15 minutes. d. Apply an ice pack to the area for 2 minutes.

A! A warm compress will promote circulation, reduce swelling, and relax muscles, thereby easing the inflammation. Witch hazel will not ease inflammation or promote muscle relaxation. Fever is not an expected response; therefore the cooling effect of a sponge bath is not necessary. The application of cold will not provide relief because it reduces circulation to the area.

Why is it important for the nurse to teach a caregiver how to monitor the oxygen saturation level of a relative who will receive home ventilator therapy? a. Potential problems can be identified and acted on before serious consequences occur. b. Performance of the assessment will allow the caregiver to identify whether the client has pain. c. Caregiver participation will allow the home care nurse to perform more advanced assessments. d. Information about the cardiac and respiratory status of the client can be used by the caregiver to change ventilator settings.

A! Alterations in oxygen saturation can provide information about impending complications, permitting early intervention. Although a low oxygen saturation may be altered in the presence of pain, it is not the most specific way to determine whether a client is experiencing pain. The nurse still should obtain the oxygen saturation level when performing an assessment of a client in the home. Nonprofessionals do not have the expertise to alter ventilator settings. Ventilator settings should be maintained as prescribed by the health care provider.

A nurse in charge in the surgical intensive care unit notes that a number of clients do not seem to be responding to morphine that was administered for pain. Later in the evening the nurse finds a staff nurse dozing in the nurses' lounge. When awakened, the staff nurse appears uncoordinated and drugged, with slurred speech. What should the nurse in charge do? a. Ask the nurse manager to be present before confronting the staff nurse. b. Ask other staff members whether they have noticed anything unusual lately. c. Tell the staff nurse that everyone now knows who has been stealing the morphine. d. Arrange to secretly observe the staff nurse the next time the staff nurse administers morphine.

A! Arranging for the nurse manager to be present before confronting the staff nurse is a serious allegation, and confrontation should occur in the presence of a person in a supervisory position. Asking other staff members whether they have noticed anything unusual is unprofessional. The nurse in charge has enough information to confront the other nurse. Telling the staff nurse that everyone now knows who has been stealing the morphine may result in an altercation; a witness should be present. Arranging to secretly observe the staff nurse the next time the staff nurse administers morphine is unprofessional; the nurse in charge has a legal responsibility to intervene.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? a. Monitor for nonverbal cues of pain. b. Check the pressure dressing for bleeding. c. Assist the client to ambulate around his room. d. Irrigate the client's nasogastric tube with sterile water.

A! Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A nurse attempts to give a client with chronic arterial insufficiency of the legs the prescribed dose of aspirin (ASA). The client refuses it, stating, "My legs are not painful." The nurse should: a. Explain the reason for the medication and encourage the client to take it b. Withhold the medication and tell the client to ask for it if the legs become uncomfortable c. Withhold the medication at this time and return to check with the client again in 30 minutes d. Request that the client take the medication and explain that it prevents the client from being uncomfortable in the next few hours

A! Aspirin is given to the client to prevent platelet aggregation and possible deep vein thrombosis. The client needs information to make an educated decision. Aspirin is not prescribed to relieve pain. The client should receive information and support before making the decision to refuse the medication. Clients should never be pressured to take medication, especially when they do not have an understanding of the risks and benefits of the medication.

Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? a. Acetylsalicylic acid (Aspirin) b. Hydromorphone (Dilaudid) c. Meperidine (Demerol) d. Alprazolam (Xanax)

A! Because of its antiinflammatory effect, acetylsalicylic acid is useful in treating arthritis symptoms. Opioids should be avoided because they promote drug dependency and do not affect the inflammatory process. Alprazolam is an antianxiety, not an antiinflammatory, agent.

nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers? a. Inspecting the skin daily b. Providing a rubber cushion on which to sit c. Massaging body lotion over reddened areas d. Applying a heating pad to bony prominences

A! Because the client is paralyzed and movement is compromised, daily inspection to determine the presence of reddened areas or lesions is necessary so that treatment can be initiated quickly. Providing a rubber cushion on which to sit may contribute to circumscribed pressure, which can lead to skin breakdown. Rubber promotes perspiration, which increases the risk of pressure ulcers. Massage of reddened areas may cause further damage and should be avoided. Because sensation may be compromised, a heating pad should not be used.

To determine when a client who had a subtotal gastrectomy can begin postoperative oral feedings, the nurse must assess for the: a. Presence of flatulence b. Extent of incisional pain c. Stabilization of hematocrit levels d. Occurrence of dumping syndrome

A! Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the gastrointestinal (GI) tract. Incisional pain is unrelated to intestinal peristalsis. Hematocrit levels indicate blood loss; they are unaffected by GI functioning. Dumping syndrome occurs after, not before, the ingestion of food and does not indicate readiness to ingest food.

After surgery a 5-year-old child experiences intense pain and an analgesic is prescribed. What should the nurse consider when administering the analgesic? a. Even though children do not like medicines, analgesics will make them more comfortable. b, Pain is not felt as strongly by children as by adults; therefore analgesics are not needed as frequently. c. Children should rarely receive analgesics because they could cause addiction or respiratory depression. d. Children do not need analgesics because they quickly return to playing or sleeping when they are distracted.

A! Children feel pain and should receive analgesics when needed. The idea that pain is not felt as strongly by children as it is by adults is a myth; it may be difficult for children to communicate pain. Not giving analgesics to children is a common but unsound belief; addiction and respiratory depression are rare. Some sources suggest that returning to play or sleep is a child's way of coping with unrelieved pain; however, it is no reason to withhold medication.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? a. Incontinence and inability to move independently. b. Periodic diaphoresis and occasional sliding down in bed. c. Reaction to just painful stimuli and receiving tube feedings. d. Adequate nutritional intake and spending extensive time in a wheelchair.

A! Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

What should the nurse do when collecting a 24-hour urine specimen? a. Check to verify if a preservative is needed. b. Weigh the client before starting the collection. c. Discard the last voided specimen of the 24-hour period. d. Assess the client's intake and output (I&O) for the previous 24-hour period.

A! Depending on the purpose of the collection, a preservative to prevent breakdown of the specimen may be necessary. Weighing the client is not necessary. The last specimen should be collected as close as possible to the end of the 24-hour period and added to the urine collected. Collecting urine for the next 24 hours, not checking the I&O for the previous 24 hours, is important.

A client with hemiparesis is reluctant to use a cane. The nurse explains to the client that the cane is needed to: a. Maintain balance to improve stability. b. Relieve pressure on weight-bearing joints. c. Prevent further injury to weakened muscles. d. Aid in controlling involuntary muscle movements.

A! Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore, greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present.

The nurse is teaching the parents of an 8-month-old infant about oral hygiene in infants. Which action by the parents indicates the need for further teaching? a. Giving honey-coated pacifiers to the child b. Avoiding rubbing the infant's teeth with salicylates c. Giving the infant fruit juice from a cup d. Avoiding bottle-feeding at night

A! Honey-coated and hard candy pacifiers increase the risk of dental caries and oral infections. Rubbing the infant's teeth with salicylates can result in infection and irritation to the oral tissue. Giving the infant fruit juice from a bottle can cause dental caries; fruit juice should only be given from a cup. Bottle-feeding during the night increases the risk of bacterial infection.

Before administering the first series of immunizations to a 2-month-old infant, the nurse tells the mother that reactions may occur. What are the characteristics of these reactions? a. Local or systemic and usually mild b. Often serious, possibly requiring hospitalization c. Sometimes causing ulceration at the injection site d. May be responsible for permanent neurological damage

A! Mild reactions consist of redness and induration at the injection site, slight fever, and irritability. Serious reactions are not common. Induration at the injection site may occur, but not ulceration. Permanent brain damage is not likely after an immunization.

A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions? a. Occipital headaches b. Generalized urticaria c. Severe muscle spasms d. Sudden drop in blood pressure

A! Occipital headaches are the beginning of a hypertensive crisis resulting from an excess of tyramine. Generalized urticaria is unrelated to the ingestion of tyramine. Severe muscle spasms are unrelated to the ingestion of tyramine. Excessive tyramine causes an increase, not a decrease, in blood pressure. Topics

A nurse teaches a client about the foods allowed on a 2-gram sodium diet. What foods does the client identify that indicates that the teaching is understood? a. Orange and apple juices b. Dried apricots and peas c. Carrot and celery sticks d. Tomato and grape juices

A! Orange and apple juices each contain 1 mg of sodium per 100 grams. Dried apricots contain 8 mg of sodium per 100 grams. Peas contain 35 mg of sodium per 100 grams; both items contain more sodium than orange and apple juices. Carrots contain 47 mg of sodium per 100 grams. Celery contains 126 mg of sodium per 100 grams; both these items contain more sodium than orange and apple juices. Tomato juice contains 200 mg of sodium per 100 grams. Grape juice contains 2 mg of sodium per 100 grams; both these items contain more sodium than orange and apple juices.

A client is receiving oxycodone (OxyContin) postoperatively for pain. The health care provider's prescription indicates that the dose should be administered every three hours for eight doses. What should the nurse assess before administering each dose of oxycodone? a. Respiratory rate and level of consciousness b. Color, character, and amount of urine output c. Intravenous site and patency of the intravenous catheter d. Amount and character of drainage in the portable drainage system

A! Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. Although urinary output of postoperative clients should be assessed, urinary output is not related directly to the administration of opioid medications. Oxycodone is administered via tablets, not intravenously. Wound drainage is unrelated to the administration of oxycodone.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? a. Encouraging daily physical exercise b. Performing yearly physical examinations c. Providing hypertension screening programs d. Teaching a person with diabetes how to prevent complications

A! Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.

A young client who has become a mother for the first time is showing signs of being anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect? a. Primary prevention b.Tertiary prevention c. Secondary prevention d. Therapeutic prevention

A! Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. The nurse recognizes that it is important to identify restrictions of mobility or neuromuscular abnormalities because: a. Shortening and eventual atrophy of the muscles will occur. b. Hypertrophy of the muscles eventually will result from disuse. c. Rigid extension can occur, making therapy painful and difficult. d. Decreased movement on the affected side predisposes the client to infection.

A! Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose to infection but to atrophy and contractures. Study Tip: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.

When communicating with a client with a psychiatric diagnosis, the nurse uses silence. When silence is used in therapeutic communication, clients should feel: a. There is no hurry to answer. b. It is their turn to talk. c. The nurse is thinking about the interaction. d. The nurse expects that further communication is unnecessary.

A! Silence is a tool employed during therapeutic communication that indicates that the nurse is listening and receptive; it allows the client time to collect thoughts, gain control of emotions, or speak without hurrying. Silence should be comfortable and should not create pressure to talk. The client should feel that she has an opportunity to think about the interaction. The client's perception that the nurse expects that further communication is unnecessary will close communication.

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the: a. Client is able to self-administer pain-relieving drugs as necessary b. Amount of medication received is determined entirely by the client c. Amount of drug used for analgesia fluctuates greatly over a given period d. Self-administration relieves the nurse of monitoring the client for pain relief

A! The ability of the client to self-administer pain-relieving medications as necessary is the purpose of patient-controlled analgesia; usually smaller amounts of analgesics are used with self-administration. The amount and dosage of the medication are programmed to prevent accidents or abuse. Drug levels are kept in a maintenance range, and pain relief is achieved without extreme fluctuations. The nurse is not absolved of responsibility when PCA is used; monitoring the client for effectiveness, refilling the apparatus with prescribed narcotic, charting the amount administered, and the client's response are required.

The nurse is teaching a group of parents of toddlers in the daycare center about accident prevention. The nurse determines that more teaching is needed when one parent states: a. "I'll keep medications in a kitchen cabinet." b. "I'll put baby gates at the top and bottom of the stairs." c. "I'll have my daughter in a regular bed by the time she's 2½." d. "I'll buy my son shoes that close with Velcro instead of laces."

A! The kitchen cabinet is not a safe place for medications; toddlers are curious and are capable of climbing and opening cabinets. They must be protected from dangerous areas such as stairs. Secured gates at the top and bottom of stairs provide a barrier. At a height of 36 inches a toddler is ready to use a bed; the average toddler reaches this height at age 2½ years. Shoes with Velcro can be secured without the need for shoelaces, which may become untied and pose a risk for falls.

Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can "sour the milk," and she indicates that she must wean her infant immediately. What should the nurse do? a. Instruct the mother about formula feeding. b. Explain to the mother that these beliefs are wrong. c. Provide the mother with books indicating that the milk does not sour. d. Encourage the mother to take an antianxiety drug while continuing breastfeeding.

A! The nurse should teach the mother how to formula feed, because cultural beliefs are deeply ingrained and it is unlikely at this time that the nurse will change the client's mind. Explaining to the mother that these beliefs are wrong is a judgmental response that does not take into consideration the client's beliefs or feelings. It is not therapeutic to contradict the client, especially when the alternative to breastfeeding will not harm the mother or infant. Providing the mother with books indicating that the milk does not sour is a judgmental response that does not recognize the client's beliefs or feelings. This is not therapeutic. Antianxiety medications are contraindicated in breastfeeding women.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? a. Low fat b. Low carbohydrate c. Soft textured and bland d. High protein and kilocalories

A! The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a high protein and kilocalories diet might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

A nurse is teaching a client who has arthritis about the steroid medication prescribed by the health care provider. Which statement about why it is important to take steroid medication at mealtime indicates that the teaching was effective? a. This will decrease gastric irritation. b. This will serve as a reminder to take the drug. c. The presence of food will enhance absorption. d. The medication is ineffective in an acid medium.

A! The presence of food limits the irritating effect of steroids on the gastric mucosa. Taking the medication at mealtime may help the client remember to take the medication, but it is not the reason for taking it with meals. Food does not increase or decrease absorption of steroids. The medication is not affected by an acid environment.

A nurse is caring for a client with dysuria. A urinary tract infection is the presumed medical diagnosis and a urine specimen in sent to the laboratory for a culture and sensitivity examination. Which component found in the client's urine indicates the presence of a urinary tract infection? a. Nitrate b. Protein c. Bilirubin d. Erythrocytes

A! The presence of nitrate in the urine is characteristic of a urinary tract infection. Nitrates are a byproduct of the breakdown of some pathogens associated with a urinary tract infection. Protein in the urine may occur for a variety of reasons; it is not specific to a urinary tract infection. Bilirubin in the urine is abnormal, but it is not related to a urinary tract infection. Erythrocytes may occur with various problems, including infection; however, they are not exclusive to infection.

While receiving an adrenergic beta2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action? a. Withhold the drug until additional prescriptions are obtained. b. Tell the client not to worry; these are expected side effects from the medicine. c. Ask the client to relax, then give instructions to breathe slowly and deeply for several minutes. d. Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.

A! These drugs cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur and the drug should be withheld until the health care provider is notified. Telling the client not to worry; these are expected side effects from the medicine, is false reassurance and a false statement. Controlled breathing may be helpful in allaying a client's anxiety; however, the drug may be producing adverse effects and should be withheld.

A 26-year-old homosexual client is diagnosed with acquired immune deficiency syndrome (AIDS). The primary nurse reports to the nursing team that the client cried when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." To best help the nursing assistant, the nurse manager must first identify that this comment most likely is a result of the nursing assistant's: a. Values and beliefs about sexual lifestyles. b. Anger and mistrust of homosexual males in general. c. Discomfort with men who are unable to control their emotions. d. Hostility over having to care for someone with a sexually transmitted infection

A! This statement reflects values and beliefs regarding homosexuality as being bad and deserving of punishment. There is not enough evidence presented to justify drawing the conclusion that the nursing assistant has anger and mistrust of homosexual males in general or discomfort with men who are unable to control their emotions. Although there may be hostility over having to care for someone with a sexually transmitted infection, no information is given to suggest that the nursing assistant has been assigned to care for this client.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? a. Elevate the head of the bed between 30 and 45 degrees. b. Decrease flow rate at night. c. Check for residual daily. d. Irrigate regularly with warm tap water.

A! To prevent aspiration, the nurse should keep the head of the bed elevated between 30 and 45 degrees. Decreasing flow rate, checking residual, and irrigating regularly will not prevent aspiration.

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing the phenomenon of: a. Tolerance b. Habituation c. Physical addiction d. Psychological dependence

A! Tolerance is a phenomenon that occurs in addicted individuals in which increasing amounts of the drug of addiction are needed to satisfy need; the client should receive adequate analgesia after surgery. Drug habituation is a mild form of psychological dependence; the individual develops a habit of taking the substance. A physical addiction is related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for usual function. Psychological dependence is emotional reliance on the substance to maintain a sense of well-being.

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? a. Alcohol b. Caffeine c. Saw palmetto d. St. John's wort

A! Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps client: a. Become aware of their personal values. b. Gain information related to their needs. c. Make correct decisions related to their health. d. Alter their value systems to make them more socially acceptable.

A! Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. The teaching should include: a. Administering water after the feeding is completed b. Maintaining the supine position during the feeding c. Heating the feeding to slightly above body temperature d. Determining tube placement by instilling water before the feeding

A! Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.

What client behavior indicates to the nurse that a woman needs further teaching about breastfeeding her newborn? a. When she leans forward to place her breast in the infant's mouth b. If she holds the infant level with her breast while in a side-lying position c. If she touches her nipple to the infant's cheek at the beginning of the feeding d. When she puts her finger in the infant's mouth to break the suction after the feeding

A! When the breast is pushed into the infant's mouth, typically the infant's mouth closes too soon, resulting in inadequate latching on. Holding the infant level with her breast while in a side-lying position facilitates latching on and maintains the infant's head in correct alignment, which promotes sucking and swallowing. Touching the nipple to the infant's cheek at the beginning of the feeding will stimulate the rooting reflex and promote latching on. Putting her finger in the infant's mouth to break the suction after the feeding prevents trauma to the nipple when the infant is removed from the breast. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. The nurse explains that a PEG tube is preferred for administering a tube feeding because: a. There is less chance of aspiration b. This procedure does not require a pump c. Self-administration of the feeding is possible d. More tube feeding mixture can be given each time

A! When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Select all that apply. a. "What brought you here for treatment today?" b. "What do you believe is the cause of your depression?" c. "Does religion have a role in your perception of health and wellness?" d. "Do you have insurance that includes coverage of mental health issues?" e. "Have you ever sought treatment for a mental health problem previously?"

A, B, C, & E! Determining the client's perception of the problem is an appropriate question that allows culturally factors to be included. Encouraging the client to discuss her problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. a. Prayer b. Hypnosis c. Medication d. Aromatherapy e. Guided

A, B, D, & E! Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates effective learning? Select all that apply. a. "I should start oral hygiene in my child." b. "I should not change my child's diet." c. "I should call my child by her name." d. "I should not leave the child with an unfamiliar relative." e. "I should encourage my child to produce n, k, g, p, and b sounds."

A, C, & D! The upper central teeth begin to erupt in a 7-month-old infant; therefore, the mother can buy a toothbrush with soft bristles to maintain oral hygiene. A 7-month-old infant can remember and respond to his or her own name. A 7-month-old infant often has a fear of the strangers, so the mother should not leave the infant with new people. A 7-month-old infant has taste preferences, so the mother can expose the child to different foods. A 7-month-old infant is able to say words such as dada, baba, kaka, etc. Therefore, the parents should encourage the infant to produce these words, not specific sounds like n, k, g, p, and b. Topics

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply. a. Take the aspirin with meals or a snack. b. Make an appointment with a dentist if bleeding gums develop. c. Do not chew enteric-coated tablets. d. Switch to Tylenol (acetaminophen) if tinnitus occurs. e. Report persistent abdominal pain.

A, C, & E! Acetylsalicylic acid (aspirin) is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Enteric-coated tablets must not be crushed or chewed. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner. Aspirin therapy may lead to GI bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately.

A school nurse is planning a class on injury prevention for a group of high school students. What guidelines should the nurse include? Select all that apply. a. Swim with a buddy. Drink beer instead of wine. c. Use well-traveled walkways. d. Smoke only in designated areas. e. Refuse to play "chicken" with others.

A, C, & E! Developmentally, adolescents have a drive for independence, an inclination for risk-taking, and a feeling of indestructibility. These traits increase the risk for injury. If one develops problems in the water, the buddy can secure help. Using well-traveled walkways reduces the risk for being alone and overcome by an individual who wishes to do harm. Refusing to play "chicken" helps the student avoid him- or herself in dangerous situations from which the student cannot retreat. Beer is alcohol, and its intake, and that of all types of alcohol, should be discouraged; when one is under the influence of alcohol, reaction time and judgment decrease and the risk for injury increases. Smoking should be discouraged to decrease the risk for respiratory disease.

The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Please select all that apply. a. Check prescription for correct client formula. b. Fill tube feeding bag with warmed formula. c. Keep the client's head of bed elevated at least 10 degrees. d. Connect tube feeding bag to client and feeding pump. e. Check for residual before beginning feeding. f. Discard any residual obtained. g. Flush with warm water before beginning feeding. h. Set correct rate and initiate pump

A, D, E, G, & H! Always check the most recent tube feeding prescription before initiating feeding. Connect the feeding bag to the client and pump and check for any residual feeding before initiating the feeding. Flush the PEG tube with 30 mL of warm water and set correct rate on pump and begin feeding. Room temperature, not warmed formula, is used. The client's head of bed needs to be elevated at least 30 degrees. Residuals obtained are reinstilled back into the stomach unless the client is a vomiting/aspiration risk. Current literature indicates that residuals of 250 mL and even greater can be reinstilled. The nurse should refer to the agency policy/procedure as well as the health care provider prescription regarding residuals.

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.

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. Correct Answer: D

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of: a. Tactile illusions associated with severed blood vessels. b. Nerve endings in the limb that are still intact and react to stimuli. c. An unconscious phenomenon to aid with grieving over the lost body part. d. Hallucinations secondary to emotional symptoms associated with the distress of amputation.

B! The neural endings that innervated the limb are still intact and may be stimulated (e.g., touch, environmental temperature, barometric pressure changes) within the residual limb. Severed blood vessels are not involved in phantom limb sensation. Although an individual must grieve over a lost body part, the grieving is unrelated to phantom limb sensation. Although phantom limb sensation is a hallucinatory-type experience, it is not part of a psychotic process.

A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? Select all that apply. a. Avoid fluid intake after 6 pm b. Drink 8 to 10 glasses of water each day c. Urinate immediately after sexual intercourse d. Increase the daily intake of carbonated beverages e. Clean the perineal area with an astringent soap twice a day

B & C! Drinking 8 to 10 glasses of water spaced throughout the day flushes the urinary tract and minimizes urinary stasis. Urination flushes the urethra and urinary meatus, limiting the presence of microorganisms. Limiting fluid intake contributes to stasis of urine. Carbonated and caffeinated beverages irritate the bladder and should be avoided. Cleaning the perineum with harsh soaps is irritating to the skin and mucous membranes, and can contribute to the development of UTIs in susceptible women.

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply. a. Eggs b. Liver c. Cheese d. Salmon e. Shellfish

B & E! Like other organ meats, liver is a high-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Shellfish (e.g., shrimp, lobster) are high-purine foods and should be avoided. Eggs have insignificant amounts of purine and are unrestricted. Cheese has insignificant amounts of purine and is unrestricted. Foods that contain a moderate amount of purine (50 to 150 mg/dL), such as salmon, may be eaten four times a week.

When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." The nurse concludes that the client: a. Needs the instructions to be repeated. b. Requires an intervention immediately. c. Does not understand the numeric scale. d. Is using humor to get the nurse's attention.

B!

The parent of a 14-month-old toddler asks the nurse how to proceed with bowel training. What is the best response by the nurse? a. Place the child on the toilet every 2 hours. b. Start by having the child sit on a potty chair. c. Avoid bowel training until the child is 2 years old. d. Begin before the child's diet consists mainly of solid foods.

B! A potty chair is sized for a child and allows the child to display its contents with pride. A potty chair also allows the child to place the feet on the floor for an effective Valsalva maneuver to aid bowel evacuation. Sitting on a toilet seat can be frightening for a toddler. Timing of bowel training should coincide with the gastrocolic reflex. Bowel training should be started whenever the child shows readiness. A diet consisting mainly of solid foods will make stools bulkier and easier to control.

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient care analgesia (PCA) pump running with a basal rate of hydromorphone (Dilaudid). The nurse assesses the client's vital signs as BP 90/60 mm Hg, heart rate 96 beats/min, and respiratory rate of 10 breaths/min. What next action should the nurse take? a. Document the findings and reassess in 2 hours. b. Turn off the pump and give naloxone (Narcan) intravenous push med (IVP) per protocol. c. Assess the client's pain level on a 10-point scale. d. Call the rapid response team.

B! A respiratory rate of 10 breaths/min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for posoperative opioid-induced respiratory depression. According to protocol, PCA status also needs to be documented every 2 hours for the first day and then every 4 hours. Pain level also is a part of the PCA documentation protocol. The rapid response team might still need to be called, but naloxone must be given first.

A nurse is assessing a newly admitted client with a pressure ulcer indicated in the picture. What stage pressure ulcer should the nurse document on the admission history and physical? a. Stage I b. Stage II c. Stage III d. Stage IV

B! A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater, has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum filled blister. A stage I ulcer has tissue injury with a purple or maroon localized area of intact skin or blood-filled blister; the area may be firm, boggy, warmer, cooler, or painful in comparison with nearby tissue. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present, it presents as a deep crater with or without undermining, and bone, tendon, or muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.

A client with rheumatoid arthritis takes aspirin (ASA) routinely to reduce pain. The client asks whether it is the arthritis, the aspirin, or some other ear problem that causes the bilateral ear buzzing the client is now experiencing. What is an appropriate nursing response? a. "The ringing in your ears is a sign of otitis media." b. "Aspirin may have damaged your eighth cranial nerve, the acoustic nerve." c. "Accumulation of cerumen, or ear wax, causes ringing in the ears." d. "Your symptoms are an expected response to the aging process."

B! ASA may damage the eighth cranial (acoustic) nerve, causing ringing in the ears and impaired hearing. Pain, not ringing in the ears, is a sign of otitis media; ASA toxicity affects the eighth cranial nerve, not the middle ear. Diminished hearing, not ringing, occurs because of mechanical obstruction of the outer ear. Aging may cause decreasing acuity in the extremes of pitch, but it does not cause ringing in the ears.

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? a. Discharge planning is not covered by insurance. b. Client cannot consent to his or her own surgery. c. Postoperative complications occur that require additional treatment. d. In case of the client's death, there will be directions about which client's belongings are to be given to family members.

B! Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

An African American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African American people?" What is the nurse's best response? a. "The prevalence of hypertension is about equal for women of all races." b. "The higher-risk population is composed of African American men and women." c. "The highest-risk population consists of older Caucasian American men and women." d. "The prevalence of hypertension is greater for African American women than for African American men."

B! African Americans represent a higher-risk population than Caucasian Americans for hypertension; the reason is unknown. African American women are more frequently affected by hypertension than are Caucasian women. African Americans of both sexes have a higher prevalence than Caucasian Americans of both sexes. African American men have a higher risk than African American women.

A female client in the terminal stage of cancer is admitted to the hospital in severe pain. The client refuses the prescribed intramuscular analgesic for pain because it puts her to sleep and she wants to be awake. One day, despite the client's objection, a nurse administers the pain medication saying, "You know that this will make you more comfortable." The nurse in this situation could be charged with: a. Assault b. Battery c. Invasion of privacy d. Lack of informed consent

B! Battery is the intentional touching of one person by another without permission of the person being touched. Assault is an intentional act without touching that makes a person fearful or produces reasonable apprehension of bodily harm. Invasion of privacy refers to the right of clients to have their private affairs protected. Informed consent applies to permission for procedures and treatments to be performed.

The nurse has provided teaching to a client with impaired balance who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client: a. Slides toward the edge of the seat before standing b. Holds both handles of the walker while rising to the standing position c. Moves forward into the walker after transferring from sitting to standing d. Stands in place holding on to the walker for at least 30 seconds before walking

B! Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position. Sliding toward the edge of the seat moves the center of gravity of the body toward the desired direction of movement, which facilitates the transfer. Holding both handles and moving forward into the walker provides the maximum support afforded by a walker. Standing in place after rising allows the body's vasomotor responses to adjust to the vertical position, minimizing orthostatic hypotension.

After a suprapubic prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. The nurse recalls that this can be achieved best by increasing the: a. Coagulability of the blood b. Velocity of the venous return c. Effectiveness of internal respiration d. Oxygen-carrying capacity of the blood

B! Because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity. Increasing the coagulability of the blood can lead to the development of deep vein thrombosis. Effectiveness of internal respiration and oxygen-carrying capacity of the blood will not affect the prevention of deep vein thrombosis.

An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant? a. Prone b. Semi-Fowler c. Left side-lying d. Supine with the head turned

B! The semi-Fowler position limits the potential for aspiration; because the infant will be partially upright, fluid is held within the stomach by gravity. The prone position permits gastric reflux and may lead to aspiration. The left side-lying position allows gastric reflux and may lead to aspiration. The supine position with the head turned allows gastric reflux and may lead to aspiration.

A nurse provides instruction when the beta blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? a. Move slowly when changing positions. b. Take the medication before going to bed. c. Expect to feel drowsy when taking this drug. d. Count the pulse before taking the medication. BBs.

B! Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition? a. Listing those fatty foods that may be included in the diet. b. Explaining that fatty foods may not be tolerated for several weeks. c. Teaching the importance of a low-calorie diet to promote weight reduction. d. Encouraging the client to join a weight reduction program in the local community.

B! Bile, which aids in fat digestion, is not as concentrated as before surgery. Once the body adapts to the absence of the gallbladder the client should be able to tolerate a regular diet that contains fat. Initially the client should avoid fatty foods unless otherwise indicated. Although teaching the client about a low-calorie diet to promote weight reduction is important, it is not as important as temporary avoidance of fatty foods with the gradual resumption of a regular diet. Encouraging participation in a weight reduction program is inappropriate at this time; a temporary avoidance of fatty foods with the gradual resumption of a regular diet is the priority.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1 Using medication to induce elimination. b. Adhering to a definite time for attempted evacuations. 3 Considering previous habits associated with defecation. 4 Timing of elimination to take advantage of the gastrocolic reflex.

B! Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? a. Checking for the last bowel movement b. Checking for residual stomach contents c. Client's head of bed elevated at least 15 degrees d. Last medication for nausea

B! Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. The general protocol is to withhold the feeding if more than 100 mL are withdrawn from the stomach. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees. Knowledge of last nausea medication is not necessary at this time.

A client is admitted to the hospital for acute pain in the hip and a total hip replacement surgery is scheduled. The client was diagnosed recently with early dementia. The client appears oriented and alert, and responds appropriately when interviewed. When the nurse is providing preoperative teaching, the client says, "I don't want to have that surgery." The client's spouse voices a desire to proceed with the surgery to provide relief for the client. The nurse should: a. Discuss with the client feelings about having surgery b. Ask the client if a power of attorney for health care has been established c. Continue with preparation for surgery as the spouse has requested d. Continue with teaching, ensuring that the client understands the process

B! Consent for surgery should be given by the client; the spouse cannot do this unless he or she has power of attorney for health care. Although it is important to discuss feelings with the client, this does not address the legal issue. The legal issue needs to be clarified first. If the client does not want surgery, preoperative teaching probably will not be effective because the client will not be receptive. The legal issue needs to be clarified first.

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements? a. Increased pulse rate b. Slowing of the heart c. Dilation of the bronchioles d. Coronary Artery Vasodilation

B! Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the principal nerve of the parasympathetic portion of the autonomic nervous system, and its axon terminals release acetylcholine. The response of the viscera to acetylcholine varies, but in general the organ is in a relaxed state. Increased pulse rate is an action of the sympathetic nervous system (accelerator nerve) caused by the release of norepinephrine. Stimulation of the sympathetic nervous system dilates bronchioles in the lungs; the vagus nerve constricts them. There are parasympathetic fibers to the coronary blood vessels; sympathetic impulses dilate these vessels. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A client is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver. The nurse suspects what type of toxicity? a. Thiamine b. Vitamin A c. Vitamin C d. Pyridoxine

B! These adaptations, as well as anemia, irritability, pruritus, and an enlarged spleen, occur with vitamin A toxicity. Excess thiamine is excreted in the urine and rarely, if ever, causes toxicity; an excessive dose may elicit an allergic reaction in some individuals. Excess vitamin C (ascorbic acid) does not cause these adaptations or toxicity; however, vitamin C may cause diarrhea or renal calculi. Pyridoxine (vitamin B6) is relatively nontoxic, and excess amounts are excreted in the urine.

A nurse is educating a client with diabetes about insulin and appropriate nutritional intake. Which statement indicates that the client understands the teaching? a. "I can eat what I want as long as I take enough insulin." b. "I can eat lots of foods as long as I stick to my exchange units." c. "I should take my regular insulin at night on an empty stomach." d. "I should eat a really small breakfast so I don't overwhelm my morning insulin."

B! Eating various foods within recommended exchange units is correct. Exchange lists allow clients to select preferred foods that are acceptable within the prescribed dietary plan. The client who believes that eating anything as long as enough insulin is taken does not fully understand the diabetic teaching. Clients should adhere to a prescribed dietary plan. The client should not take regular insulin at night on an empty stomach but should have a snack before going to bed to prevent nighttime episodes of hypoglycemia. The client should eat a preset balanced breakfast, not a very small one, because it is calculated into the entire plan to balance nutrition, insulin, and exercise.

A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day? a. Paresthesias of the feet b. Shortening of the muscles c. Development of osteoblasts d. Loss of muscular coordination

B! Flexion and extension prevent tightening of muscles and tendons. Abnormal sensations (paresthesias) are related to neurological, not musculoskeletal, alterations. Weight bearing, not exercise, promotes the development of osteoblasts. Loss of muscular coordination is the result of cerebellar changes; it is not related to immobility. Study Tip: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

A nurse is teaching the parents of an 8-year-old child who is taking a high dose of prednisone (Meticorten) for asthma. What critical information about prednisone should be included? a. It protects against infection. b. It should be stopped gradually. c. An early growth spurt may occur. d. A moon-shaped face will develop.

B! Gradual weaning from prednisone (Meticorten) is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The drug usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? a. Encourage rest. b. Obtain vital signs. c. Administer the prescribed analgesic. d. Document the client's pain response.

B! Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiologic rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.

A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? a. Monitor the client's pain level for another hour. b. Determine the integrity of the intravenous delivery system. c. Reprogram the pump to deliver a bolus dose every eight minutes. d. Arrange for the client to be evaluated by the health care provider.

B! Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.

In the postanesthesia care unit it is reported that the client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care? a. Assessing the client for tachycardia b. Monitoring of respiratory rate hourly c. Administering naloxone every three to four hours d. Observing the client for signs of central nervous system (CNS) excitement

B! Intrathecal morphine can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia and hypotension occur. Administering naloxone every three to four hours is too long if the client's respirations are depressed. The recommended adult dosage usually is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs secondary to hypoxia.

An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube? a. Once a day b. Before each feeding c. At every shift change d. During the night shift

B! It is the nurse's responsibility to assess tube placement before each feeding; withdrawing gastric contents before each feeding ensures that the tip of the tube is in the stomach. The other times are not frequent enough; the tube could be displaced between feedings.

A nurse teaches a client with varicose veins about prevention of a thromboembolus. Which statement regarding preventive measures indicates that the client requires further teaching? a. "I must increase my fluid intake." b."I will massage my legs twice a day." c. "Elastic stockings should be put on before getting out of bed." d. "Involving my upper and lower extremeties in all exercises is important.

B! Massaging the legs twice a day is unsafe if a thrombus is present because it may dislodge and cause an embolus. Fluids decrease blood viscosity, reducing the risk for thrombus formation. Elastic stockings physically compress veins, preventing venous stasis and lowering the risk for thrombus formation. Range-of-motion exercises prevent venous stasis and promote muscle tone; they propel venous blood toward the heart, facilitated by venous one-way valves.

The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? a. There is an increased risk of side effects in infants. b. Maternal antibodies provide immunity for about 1 year. c. It interferes with the effectiveness of vaccines given during infancy. d. There are rare instances of these infections' occurring during the first year of life.

B! Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies.

After surgery for a ruptured appendix, a 12-year-old child is receiving morphine for pain control by way of a patient-controlled analgesia (PCA) infusion. A bolus of morphine can be delivered every 6 minutes. A parent will be staying with the child during the immediate postoperative period. What statement indicates to the nurse that the instructions about the PCA pump have been understood? 1 "I'll make sure that she pushes the PCA button every 6 minutes." Correct2 "She needs to push the PCA button whenever she needs pain medication." 3 "I'll have to wake her up on a regular basis so she can push the PCA button." 4 "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping." Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

B! Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

A client receives a prescription for nitroglycerin (Nitrostat) sublingual as needed for anginal pain. What should the nurse include in the teaching about this medication? a.To facilitate absorption, drink a large glass of water after taking the medication b. Place the tablet under the tongue or between the cheek and gum c. It takes 30 to 45 minutes for the nitroglycerin to achieve its effect d. If dizziness occurs, take a few deep breaths and lean the head back

B! Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Clients are instructed to place the tablet under the tongue or between the cheek and gum, and let it dissolve. The client should not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving; this will decrease the effectiveness of the drug. If taken with water, the tablet is washed away from the site of absorption or may be swallowed. Nitroglycerin sublingual tablets usually give relief in one to five minutes. If a client experiences dizziness or lightheadedness, the client is instructed to take several deep breaths and bend forward with the head between the knees. This position promotes blood flow to the head.Content Area: Cardiovascular System, Blood, and Lymphatic Systems

A client who has become a mother for the first time appears anxious about her new parenting role. The nurse recommends that she join a support group for new mothers at the local YWCA. Which type of prevention is this? a. Tertiary b. Primary c. Secondary d. Therapeutic

B! Primary prevention is focused on health promotion and illness prevention. Tertiary prevention is focused on rehabilitation and the reduction of residual effects. Secondary prevention is focused on early detection and treatment. No type of prevention is specifically known as therapeutic; however, all types of prevention should be therapeutic. Topics

A nurse is admitting a client to the unit. What interaction demonstrates effective therapeutic communication principles? a. Speaking slowly to convey calm and relaxation b. Maintaining a distance of at least 3 feet from the client c. Asking closed-ended questions to help secure desired information d. Requesting an interpreter if the client's English cannot be understood

B! Respecting personal space is a basic principle of therapeutic communication. A separation of 3 to 6 feet is considered appropriate and comfortable for nurse-client conversations. Although communication is facilitated by a calm, relaxed environment, it will not have an impact on the therapeutic nature of a conversation between the nurse and the client. Sometimes a closed-ended question may be appropriate, but this technique usually serves as a barrier to effective therapeutic communication. Although calling for an interpreter is an appropriate intervention, it will not have an impact on the therapeutic nature of a conversation between the nurse and the client.

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent? a. A nursing diagnosis b. An inaccurate interpretation c. A correct nursing assessment d. An accurate conclusion if crepitus was ruled out

B! Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? a. A statement that the nursing staff was not at fault because the client initiated the accident. b. A listing of facts related to the incident as witnessed by the nurse. c. The name of the nurse who was responsible for implementing the restraints. d. The potential reasons why the restraints were not in place at the time of the fall.

B! The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? a. Maintain the head of the bed at 35 degrees or less. b. With the help of another staff member, use a drawsheet when lifting the client in bed. c. Reposition the client at least every 2 hours and support the client with pillows. d. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

B! Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows and at least once every 8 hours, and performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on: a. Alternating sides b. The right side c. The side of the weakness d. The side of the client's choice

B! The cane should be used on the stronger (unaffected) side of the body to add strength, decrease dependence on the weaker (affected) side, and aid in balance during ambulation. Correct use of a cane does not involve alternating sides, using the cane on the affected (weaker) side, or using the side of the client's choice.

The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen? a. Start urinating in the cup and then finish urinating in the toilet. b. With the enclosed towelettes, wipe your labia from front to back before collecting the specimen. c. If you can't fill the cup then leave it on the toilet and use it again when you void next time. d. When you finish, leave the cup on the back of the toilet and when the aide makes rounds, she'll get it.

B! The client must use the packaged towelettes and wipe the labia from front to back before urinating. The client needs to urinate a small amount in the toilet first and then hold the cup under the perineal area and finish urinating in the cup. If the client cannot void enough for a specimen then discard that one and obtain another specimen when the client can void a sufficient amount. Tell the client to notify the nurse immediately after the specimen is collected so it can be sent to the laboratory for analysis.

When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." The nurse concludes that the client: a. Needs the instructions to be repeated. b. Requires an intervention immediately. c. Does not understand the numeric scale. d. Is using humor to get the nurse's attention.

B! The client reported a number as instructed but chose a number beyond the stated intensity scale. When numbers above 10 are identified, clients are communicating that the pain is excessive; immediate nursing action is indicated. It is not likely that the client misunderstood the instructions or does not understand the numeric scale; the client reported a number as instructed but chose a number beyond the stated intensity scale. The client has the nurse's attention; the use of humor is not commonly associated with clients in pain.

A nurse in the pediatric clinic plans to administer a booster immunization for polio to a child. Which vaccine should the nurse administer? a. Hib b. IPV c. OPV d. DTaP

B! The current polio vaccine is the inactivated polio vaccine (IPV; Salk vaccine) that is injectable. Hib is the Haemophilus influenzae type b vaccine. OPV is the oral polio vaccine (Sabin vaccine); it is no longer administered because it is related to vaccine-associated polio paralysis. However, it is used in the worldwide effort to eliminate the virus in countries where it is endemic. DTaP is the diphtheria, tetanus, and acellular pertussis vaccine.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? a. Client has a low pain tolerance. b. Medication is not adequately effective. c. Medication has sufficiently decreased the pain level. d. Client needs more education about the use of the pain scale.

B! The expected effect should be more than a 1-point decrease in the pain level. Identifying whether a client has a low pain tolerance cannot be determined with the data available. The medication has not achieved an adequate response; pain generally is considered to be tolerable if it is 4 or below on a pain scale of 1 to 10. Determining that the client needs more education about the use of the pain scale cannot be determined with the data available.

A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag? a. Auscultating for breath sounds b. Removing the tube, then reinserting it c. Administering the tube feeding slowly d. Observing the infant for circumoral cyanosis

B! The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.

A nurse is planning to give a preschool child an immunization consisting of bacterial cells that have been modified. What is the substance called? a. A toxoid b. A vaccine c. An allergen d. An antitoxin

B! The microbes in the vaccine have been modified so they will not cause active infection but will still elicit an immune response. A toxoid is a modified toxin in which the poisonous properties have been destroyed but the toxin is still capable of producing antibodies. An allergen is a substance that causes an allergic reaction. An antitoxin is an antibody that is capable of neutralizing a specific toxin.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective? a. Apples b. Broccoli c. Cherries d. Cauliflower

B! Thiazide diuretics are potassium-depleting agents; broccoli provides 267 mg of potassium per 100 grams. Apples provide 80 to 110 mg of potassium per 100 grams of fruit. Cherries provide 191 mg of potassium per 100 g of fruit. Cauliflower provides 206 mg of potassium per 100 g.

A client with irritable bowel syndrome has instructions to take psyllium (Metamucil) two rounded teaspoons full twice a day for constipation. What is most important for the nurse to include in the teaching plan? a. Urine may be discolored. b. Each dose should be taken with a full glass of water or juice. c. Stop taking the laxative once a bowel movement occurs. d. Daily use may inhibit the absorption of some fat-soluble vitamins.

B! This bulk-forming laxative works by absorbing water into the intestine, which increases bulk and distends the bowel to initiate reflex bowel activity, thus promoting a bowel movement. A full glass of fluid taken at the same time will help minimize the risk of esophageal obstruction or fecal impaction. Senna, a stimulant laxative, may cause urine discoloration. Bulk-forming laxatives, such as psyllium, are the only laxatives that are recommended for long-term use and in cases of irritable bowel syndrome; they are used to prevent constipation and therefore should not be stopped once a bowel movement occurs. Prolonged use of lubricant laxatives, such as mineral oil, can inhibit the absorption of some fat-soluble vitamins.

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record? a. "Has intact plantar reflexes." b. "Exhibits a positive Babinski sign." c. "Demonstrates normal sensory function." d. "Able to perform active range of motion."

B! This is a positive Babinski sign ; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. Demonstrating normal sensory function is an abnormal reflex; it is not an indication of normal sensation. Being able to perform an active range of motion exhibits an abnormal reflex; it is not caused by intentional movement.

A nurse in the daycare center is teaching several aides about the play behavior of 2-year-old toddlers. What is this type of play called? a. Group b. Parallel c. Dramatic Cooperative

B! Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

The mother of a 17-year-old adolescent who is going to be a foreign exchange student asks the nurse why her child must have a tetanus toxoid immunization instead of the immune globulin. The nurse responds that the tetanus toxoid immunization provides: a. Lifelong passive immunity b. Longer-lasting active immunity c. Temporary active natural immunity d. Temporary passive natural immunity

B! Toxoids are modified toxins that stimulate the body to form antibodies that can last up to 10 years against the specific disease; because the adolescent will be in a foreign country, the toxoid is given prophylactically. The tetanus toxoid provides active, not passive, immunity; all passive immunity is short acting. Only by having the disease can someone gain natural immunity. Toxoids confer active, not temporary passive, immunity. Topics

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? a. Determine if this is an allergic reaction b. Place the client in the supine position and take the vital signs c. Elevate the client's head and keep the extremities warm d. Tell the client that this is not a typical sensation after receiving morphine sulfate

B! Vertigo is a symptom of hypotension, a side effect of morphine sulfate. The supine position increases venous return, increases cardiac output, and increases blood flow to the brain. Dizziness is a symptom of hypotension that is a side effect, not an allergic response, to morphine sulfate. Raising the client's head may aggravate dizziness. Dizziness is a typical side effect of morphine sulfate.

A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, the nurse should teach the client to: a. Shorten the stride of the unaffected extremity b. Advance the cane and the affected extremity simultaneously c. Lean the body toward the side with the cane when ambulating d.Hold the cane on the same side as the affected extremity and increase the base of support

B! Advancing the cane and the affected extremity simultaneously supports stability. The body is supported partially on the affected limb and partially on the cane as the unaffected limb moves forward. Shortening the stride of the unaffected extremity will produce an awkward gait and instability; normal ambulation should be approximated. Leaning the body toward the cane when ambulating will change the center of gravity and cause instability. The cane is held on the unaffected, not the affected, side and advanced at the same time as the affected extremity to increase the base of support and provide stability.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. The nurse can best assess the client's pain level by: a. Asking the client's parent b. Using Wong's "Pain Faces" c. Observing the client's body language d. Explaining the use of a 0 to 10 pain scale

B! An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A nurse has just finished feeding a 4-year-old child through a nasogastric tube. In what position should the child be placed to help ensure retention of the feeding and prevent aspiration? a. Supine b. Semi-Fowler c. Trendelenburg d. Left side-lying

B! The semi-Fowler position limits the potential for aspiration; the child will be partially upright and fluid will remain in the stomach by means of gravity. The supine, Trendelenburg, and side-lying positions all allow gastric reflux and may lead to aspiration.

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? Select all that apply. a. Reduce calcium intake. b. Change positions slowly. c. Report peripheral edema. d. Expect temporary hair loss. e. Avoid drinking grapefruit juice.

B, C, & E! Changing positions slowly helps reduce orthostatic hypotension. Peripheral edema may occur as a result of heart failure and must be reported. Grapefruit juice affects the metabolism of calcium channel blockers and should be avoided. Reducing calcium intake is unnecessary because calcium levels are not affected. Hair loss does not occur.

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Select all that apply. a. "Your child should be able to show the grasp reflex." b. "Your child should be able to coo, babble, and chuckle." c. "Your child should be able to pull at blankets or clothes." d. "Your child should be able to put feet into the mouth when supine." e. "Your child's head can come up to a 45- to 90-degree angle from the table."

B, C, & E! Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply. a. Age b. Anorexia c. Hemiplegia d. History of diabetes e. Urinary incontinence

B, C,D, & E! Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this impacts on the categories of mobility, activity, and friction on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not used in the Braden Scale. Diseases are not used on the Braden Scale.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. a. The client will become capable of part-time employment. b. The client will effectively express emotional and physical needs. c. The client will demonstrate wellness reflective of physical potential. d. The client will demonstrate an understanding of the mental health disorder. e. The client will recognize the issues most important to managing this disorder.

B, D, & E! Therapeutic communication facilitates the exchange of information between the nurse and the client that focuses on the client's attaining health and wellness. This information can be directed towards the client's health needs such as the effective expression of the client's physical and emotional needs, the understanding of the cause and prognosis of the current mental health problem, and the recognition of issues important to the management of the client's health issues. The client's ability to maintain part-time employment and the client's physical health potential are minimally affected by therapeutic communication.

A client is receiving morphine sulfate (MS Contin) for severe metastatic bone pain. To prevent complications from a common, serious side effect of morphine, the nurse should: a. monitor for diarrhea b. observe for an opioid addiction c. assess for altered breathing patterns d. check for a decreased urinary output

C! Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Although morphine sulfate may cause urinary retention, it is not a common side effect and is not life threatening.

A nurse in the pediatric clinic discusses the nutrition and feeding needs of an 18-month-old toddler with the child's parents. What information should the nurse include? a. Growth rate increases, so more protein is needed per pound of body size. b. Energy requirements become so high that more calories are needed to meet them. c. Struggling for autonomy may involve refusal of food, but they will eat the amount they need. d. Three meals a day should be offered, with no between-meal snacks, because they are finicky eaters.

C! A toddler's increasing mobility and growing independence affects eating behaviors; slowed physical growth at this age requires relatively fewer calories. A toddler's growth rate and energy requirements decrease compared with the first year of life. Nutritious snacks between meals should be encouraged if the toddler is not eating adequate meals.

A 10-year-old child who is developmentally delayed and blind must be fed all meals. The child has problems swallowing and frequently chokes and coughs during the feeding. What technique should the nurse use when feeding this child? a. Holding the child in an upright position and using a soft-tipped bulb syringe b. Placing the child in the supine position and turning the child's head to the right c. Seating the child in a wheelchair, giving small bites of food with metal tableware, and encouraging participation d. Propping the child in a semisitting position, providing chopped food, and placing it in the child's mouth with plastic tableware

C! An upright position helps prevent aspiration; gravity facilitates movement of food down the esophagus and into the stomach. Metal tableware is safer than plastic tableware because it is unbreakable; a mentally challenged child could easily bite down on and break a plastic utensil and choke on the fragments. Encouraging participation, with socialization, and treating the child with dignity should be part of the meal. Although the child might assume an upright position, using a syringe is a form of forced feeding; in addition, the child should be encouraged to eat solid foods. Feeding in the supine position puts the child at risk for aspiration and choking. Solid, not chopped, food should be encouraged.

On which principle should a nurse base client teaching when planning to assist a client to reestablish a regular pattern of defecation? a. Sedentary activities produce muscle atony. b. Increased fluid promotes ease of evacuation. c. Peristalsis is initiated by the gastrocolic reflex. d. Increased potassium is needed for normal neuromuscular irritability.

C! Because stomach distention after eating results in contractions of the colon (gastrocolic reflex), which promotes defecation, establishing some regularity of meals that include adequate bulk or fiber will help establish routine patterns of defecation. Although exercise and increased fluid facilitate elimination, in general they do not help to establish a pattern of defecation. Increased potassium is not needed for normal elimination.

A gavage feeding is prescribed for an infant. How does the nurse determine the length of tube needed to reach the stomach? a. The tube is advanced until resistance is met. b. The tube is advanced until gastric contents are aspirated. c. A measurement is made from nose to earlobe and then to the epigastric area. d. A measurement is made from mouth to umbilicus and then half that distance is added.

C! Before inserting the gastric tube, the nurse measures the anatomical pathway that the tube will travel, which is from the nose to the earlobe (corresponding to the nasopharynx) to the epigastric area of the abdomen (the lower end of the stomach). The tube is then marked and inserted until the mark is reached. Advancing the tube without measuring for the potential length of the tube to reach the stomach is unsafe. Without premeasuring, the tube may be advanced too far or not far enough. Inserting the tube to the point where gastric contents are aspirated may not place the tube well into the stomach, which can increase the risk of aspiration. Measuring from mouth to umbilicus and then adding half that distance will yield a distance that is too long.

A 6-month-old infant is to receive scheduled immunizations. The parents ask why two influenza vaccines are given: Haemophilus influenzae type B (Hib) and pneumococcal conjugate vaccine (PCV). How should the nurse respond? a. PCV prevents influenza. b. Hib is given to prevent pneumonia. c. Hib and PCV prevent different bacterial diseases. d. PCV and Hib are given together to protect against viral and bacterial diseases.

C! Both vaccines protect against bacterial infections. The PCV protects against bacterial pneumonia. The Hib vaccine protects against bacterial infections caused by Haemophilus influenzae type B; these include otitis media, meningitis, epiglottitis, septic arthritis, and sepsis. The PCV conjugate vaccine protects against infections caused by the Streptococcus pneumoniae bacterium (pneumococcal pneumonia). Topics

health care provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure? a. Facilitates vasodilation b. Promotes smooth muscle relaxation c. Reduces the circulating blood volume d. Blocks the sympathetic nervous system

C! Diuretics block sodium reabsorption and promote fluid loss, decreasing blood volume and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Drugs that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.

The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make? a. Join a gym. b. Drink fewer diet sodas. c. Decrease fast food intake. d. Take a multivitamin daily.

C! Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.

An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance? a. Retention of potassium in the cells b. Loss of fluid by way of the kidneys c. Loss of chloride ions through vomiting d. Reduction of blood supply to body cells

C! Electrolyte deficits, rather than urinary excretion, precipitate an acid-base imbalance. Loss of gastric secretions, which contain sodium, chloride, and potassium, usually results in metabolic alkalosis. With vomiting, a depletion of cellular potassium occurs. Electrolyte deficits, rather than inadequate blood supply, can precipitate an acid-base imbalance.

The primary health care provider instructs the nurse to apply an emollient to an infant. During assessment, the nurse finds that the neonate is preterm and has a body weight of 900 g. Which is the appropriate nursing intervention in this situation? a. Administer intravenous fluids before applying emollient. b. Avoid applying emollient to dry, flaking, and fissured areas of the skin. c. Monitor for coagulase-negative staphylococcus infection. d. Do not apply emollient and recheck with the primary health care provider.

C! Emollients can cause coagulase-negative staphylococcus infection in a preterm infant who weighs less than or equal to 900 g. Intravenous fluids do not increase the effectiveness of emollients, so there is no need to administer intravenous fluids before applying the emollient. Emollients effectively reduce dry, flaking, and fissured areas on the infant's skin. Emollients are not contraindicated in preterm infants, so there is no need to avoid application or to recheck with the primary health care provider. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.

A nurse on the adolescent unit is planning to discuss smoking prevention. What is the most effective approach for the nurse to use? a. Sharing personal experiences with a smoking-cessation program b. Showing pictures of the effects of smoking on the cardiopulmonary system c. Presenting information on how smoking affects appearance and odor of the breath d. Citing statistics about the relationship between smoking and cardiopulmonary diseases

C! Establishing an identity is the major developmental task of the adolescent; to achieve this task, the adolescent needs to conform to group norms that include appearance and acceptance. Appealing to this need may achieve more success than other teaching strategies. Sharing personal experiences with a smoking-cessation program is a teaching strategy that may be successful with an older, more secure group of people. Adolescents tend to believe that they are invincible and probably will not relate to this teaching strategy. They are also concerned about the present, not the future. Because adolescents believe they are invincible, they would not relate to a teaching strategy based on statistics about the harmful effects of smoking. Study Tip: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? a. Give aspirin for pain; if swelling at the injection site develops, call the health care provider. b. Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed. c. Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures. d. Apply ice to the injection site if soreness develops; call the health care provider if the child comes down with a fever

C! Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the health care provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the health care provider.

An 18-month-old child has received all required immunizations. What immunization should the nurse explain to a parent will be one of the vaccines required between 4 and 6 years of age? a. Rotavirus b. Hepatitis B c. Inactivated poliovirus d. Haemophilus influenzae type b

C! Four doses of inactivated poliovirus are administered: at 2 months, 4 months, between 6 and 18 months, and between 4 and 6 years. Rotavirus vaccines are administered at 2, 4, and 6 months of age. The first dose of hepatitis B vaccine is administered at birth, the second dose is administered between 1 and 2 months of age, and the third dose is administered between 6 and 18 months of age. Haemophilus influenzae type b vaccines are administered at 2, 4, and 6 months of age, and a fourth dose is given between 12 and 15 months of age.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? a. "Moderate amount of drainage." b. "No change in drainage since yesterday." c. "A 10-mm-diameter area of drainage at 1900 hours." d. "Drainage is doubled in size since last dressing change."

C! Gradual weaning from prednisone (Meticorten) is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The drug usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.

The nurse is teaching the Hispanic parents of a preschool child about the prevention of lead poisoning. Which statement by the parents indicates a need for further teaching? a. "We'll use cold water to cook and drink." b. "We know to not store food in open cans." c. "We can use orange powders for diarrhea." d. "We'll start planning healthy midmorning and afternoon snacks."

C! Greta and azarcon (also known as alarcon, coral, luiga, maria luisa, and rueda), traditional Hispanic remedies taken for upset stomach, constipation, diarrhea, and vomiting, are also used for teething babies. Both are fine orange powders with a lead content as high as 90%. Further teaching is required if the family indicates that they will continue treating diarrhea with a home remedy. Food should not be stored in open cans, particularly those that have been imported. Cold water for consumption (drinking, cooking, and especially reconstitution of powdered infant formula) should be used; hot water dissolves lead more quickly than does cold water, yielding a higher level of lead. Frequent healthy snacks are encouraged because lead is absorbed better on an empty stomach.

An 11-month-old infant with iron-deficiency anemia is started on an oral iron supplement. What information should the nurse include when teaching the parents about the side effects of iron supplements? a. The urine may turn red. b. The skin will turn yellow. c. The teeth may become stained. d. The stools will take on a clay color.

C! Liquid oral iron supplements may stain the teeth; brushing the teeth after administration may limit the discoloration. There should be no change in the color of the urine. Yellowing of the skin is a sign of jaundice; it is not a side effect of an iron supplement. The stools will become black-green; clay-colored stools are a sign of biliary obstruction.

A nurse is teaching a class to parents about keeping medications and household cleaning supplies out of the reach of toddlers. The nurse explains that this is necessary because toddlers: a. Have increased appetites b. Are developing a sense of taste c. Have a high level of oral activity d. Are rebelling against parental authority

C! One way in which toddlers explore their environment is by putting objects in their mouths. An expected decline in appetite occurs during this period; it is called physiologic anorexia. The sense of taste is developed at birth. Toddlers assert themselves but are not rebellious against adult authority; adolescents rebel against adult authority.

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, the nurse should teach the client range-of-motion exercises, specifically: a. Eversion b. Supination c. Opposition d. Circumduction

C! Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? a. Crying b. Splinting c. Perspiring d. Grimacing

C! Perspiration is an involuntary physiologic response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain. Crying is an emotional response that may or may not be related to pain. Splinting is a voluntary action that may limit tension on the abdomen, thus reducing pain. Grimacing is a result of contraction of the facial muscles; it may or may not be a response to pain.

A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. The nurse should teach the client to: a. Place the back legs of the walker about 10 inches in front of the feet, shift the body weight to the walker, and step forward b. Move the walker about 8 inches forward while stepping forward to the walker, with body weight on the walker and both legs c. Place the walker flat on the floor with the front legs about 12 inches in front of the feet, shift the body weight to the walker, and step forward to take initial steps d. Move the walker about 10 inches in front of the feet with only the front legs of the walker on the floor, then step forward and put the walker flat

C! Placing the walker flat on the floor provides stability; putting weight on the walker equalizes weight bearing on the upper and lower extremities. Placing the back legs of the walker about 10 inches in front of the feet, shifting the body weight to the walker, and stepping forward places the walker too far in front of the client for safe transfer of body weight; also, all four legs should be flat on the ground. It is not possible to move the walker and have it bear weight at the same time; the walker should be flat on the ground when the client is stepping forward. All four points of the walker should be flat on the ground when the client is stepping forward.

An 18-year-old is admitted with an acute onset of right lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? a. Urinary retention b. Gastric hyperacidity c. bound tenderness d. Increased lower bowel motility

C! Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

A nurse has provided discharge instructions to a client that received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: a. Picks up the walker and carries it for short distances b. Uses the walker only when someone else is present c. Moves the walker no more than 12 inches in front of the client during use d. States that a walker will be purchased on the way home from the hospital

C! Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

How can a nurse best accomplish therapeutic communication with an adolescent? a. By using teen language b. By relating on a peer level c. By establishing a relationship over time d. By interacting with the use of concrete concepts

C! Several meetings with an adolescent will provide an opportunity to develop trust and establish a relationship. Using teen language is not necessary and may not help establish a relationship. Relating on a peer level is not realistic because the nurse is not the teenager's peer. It is not necessary to communicate in concrete terms because the average adolescent is past this cognitive level.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? a. "Hospital policies should put a stop to this." b. "Everyone should conform to the prevailing culture." c. "Nontraditional approaches to health care can be beneficial." d. "You are right because they may have a negative impact on people's health."

C! Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

A 16-year-old male student who was injured while skateboarding arrives in the emergency department with a deep laceration of his leg. He does not remember when he received his last tetanus immunization. The nurse explains that tetanus immunoglobulin (TIG) and tetanus toxoid are required because: a. Neither medication is effective alone. b. Both eliminate the need for additional medications. c. Different mechanisms are used to stimulate the immune response. d. Tetanus toxoid minimizes the risks related to the tetanus immunoglobulin.

C! TIG provides immediate protection, whereas the tetanus toxoid initiates an active immune response. Each is effective alone, but the combination is preferred. They do not confer lifelong immunity. After the initial routine immunizations and boosters, it is recommended that the tetanus toxoid be administered every 10 years. TIG does not carry major side effects because it is derived from human

A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy? a. Hib (influenza) b. HepB (hepatitis B) c. MMR (measles, mumps, rubella) d. DTaP (diphtheria, tetanus, acellular pertussis)

C! The MMR vaccine contains attenuated live virus and should not be administered to a child undergoing chemotherapy because of the compromise of the child's immune system. There are no contraindications to administering the Hib vaccine HepB vaccine, or DTaP vaccine to a child who is immunosuppressed.

Before administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? a. Returning the aspirate and withholding the feeding b. Discarding the aspirate and administering the full feeding c. Returning the aspirate and subtracting the amount of the aspirate from the feeding d. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

C! The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

After teaching a family member how to administer subcutaneous enoxaparin sodium (Lovenox), how should a nurse evaluate the effectiveness of the training? a. Return demonstration on a manikin. b. Verbalization of the side effects of the medication. c. Observing the family member administering enoxaparin sodium to the client. d. Correctly verbalizing all necessary steps in enoxaparin sodium administration.

C! The best way to evaluate the effectiveness of the teaching is to observe the family member administering the medication to the client. The family member may be able to perform a subcutaneous injection on a manikin, but fear hurting their family member. Knowing the side effects of enoxaparin sodium is important, but it does not provide any information as to their ability to administer the medication. The family member may be able to verbalize all the steps, but fear puncturing the skin with the needle.

A nurse is teaching a client with hemiparesis how to ambulate with a cane. The nurse should instruct the client to: a. Shorten the stride of the unaffected extremity b. Lean the body toward the cane when ambulating c. Advance the cane simultaneously with the affected extremity d. Hold the cane in the hand on the side of the affected lower extremity

C! The cane is held on the unaffected side and is advanced at the same time as the affected extremity; this increases the base of support and provides stability. Shortening the stride of the unaffected extremity will produce an awkward gait and instability; regular ambulation should be approximated. Leaning the body will change the center of gravity and cause instability. Holding the cane in the hand on the side of the affected lower extremity does not provide for a wide base of support or stability.

The nurse is teaching crutch-walking to a 12-year-old child. What does the child do that indicates the need for more teaching? a. Takes short steps of equal length b. Looks forward to maintain balance c. Looks down when placing the crutches d.Assumes an erect posture when walking

C! The child should maintain an erect walking posture, without looking down, to ensure equilibrium and avoid losing balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips

How should a nurse assess a 4-year-old child with abdominal pain? a. By asking the child to point to where it hurts b. By auscultating the child's abdomen for bowel sounds c. By observing position and behavior while the child is moving d. By questioning the parents about their child's eating and bowel habits

C! The child with abdominal pain may assume the side-lying position with the knees flexed to the abdomen or self-splint when moving. A 4-year-old may be unable to identify the exact location of the pain; in addition, the pain may be generalized rather than localized. Auscultation may be included in the physical assessment, but it is not specific to the assessment of pain. Questioning the parents may be included when the nurse is taking the health history, but it is not specific to the current assessment of pain.

A 4-month-old infant is admitted to the pediatric unit. How does the primary nurse expect the infant to behave when approached? a. Smile socially in recognition of the nurse b. Cry when the nurse approaches for the first time c. Reach out to the nurse for the attention that is being offered d. Cling to the mother when the nurse tries to establish contact

C! The infant has not yet recognized boundaries between self and mother and is not particular about who meets and resolves needs. The infant is most likely reaching out for attention. A social smile does not indicate recognition of a specific person, only a human face. The infant does not yet differentiate familiar faces from those of strangers. The infant does not understand or fear separation from the mother yet.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? a. Portal hypotension b. Kidney malfunction c. Diminished plasma protein level d. Decreased production of potassium

C! The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. Potassium is not produced by the body, nor is its major function the maintenance of fluid balance.

The parents of a newborn discuss their infant's need for immunizations with the nurse. Which vaccine will not be administered until the child is at least 12 months of age? a. Polio b. Tetanus c. Measles d. Pertussis

C! The measles vaccine is not given before 12 months of age because the child still has passive natural immunity from the mother. Polio, tetanus, and pertussis vaccines are given during the first 6 months of life.

The nurse is teaching safe transportation techniques to the parents of a baby who are from a low economic background. Which advice given by the nurse is appropriate? a. "You should borrow or buy a secondhand car seat." b. "You should place padding in the car seat behind the baby." c. "You should place the baby's car seat in the rear-facing position in the back seat." d. "You should buy an infant-only model and an infant/toddler convertible car seat."

C! The nurse instructs the parents to place the baby's car seat in the rear-facing position in the back seat, as it prevents injury to the infant from the air bag in case of a crash. It is dangerous to borrow or buy secondhand car seats. Placing padding behind the baby will create slack in the harness, which may result in the baby being ejected from the seat in case of a crash; therefore, this is not a safe intervention. The parents of the baby are from a low economic background. Therefore, convertible-type car seats are preferable. Though convertible-type seats cost more initially, they work out to be less expensive than buying both an infant-only model and an infant/toddler convertible model. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these lookalike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? a. Temperature b. Neurological status c. Respirations d. Urinary output

C! The nurse must be especially alert to any changes in respirations, because morphine decreases the respiratory center function in the brain. An order for morphine should be questioned if the baseline respirations are less than 12 per minute. Neurological status along with pulse and blood pressure would be a priority assessment after respiratory rate. Measurements of temperature and urinary output are part of the overall client assessment but not a priority with morphine.

If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already? a. Measles, mumps, and rubella vaccine b. Booster dose of inactivated polio vaccine c. Two doses of diphtheria, tetanus, and pertussis vaccine d. First booster dose of diphtheria, tetanus, and pertussis vaccine

C! The schedule for active immunization is three doses of diphtheria, tetanus, and pertussis (DTaP) at 2-month intervals beginning at 2 months of age. The measles, mumps, and rubella vaccine is not given until 12 to 15 months because maternal antibodies block the formation of the infant's antibodies. An inactivated polio vaccine booster (fourth dose) is due at 4 to 6 years of age. The first booster dose of DTaP is given at 15 to 18 months, or approximately 1 year after the third dose that is given at 6 months of age.

A nurse is teaching a client with hypertension about a sodium-restricted diet. What information should the nurse emphasize? a. Using salt-free natural seasonings can taste the same as salt. b. Desiring the taste for salt is inherent but can be overcome with practice. c. Liking the taste of table salt is learned but it is not a biological necessity. d. Substituting table salt with potassium chloride can be done freely.

C! The taste for salt is learned from habitual use and can be unlearned or reduced with health improvement motivation and creative salt-free food preparation. Substitutes do not taste the same as salt. The taste for salt is learned. Using salt substitutes containing potassium chloride may be unsafe; excessive use can produce abnormally high serum potassium levels.

A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the nurse discusses prevention of esophageal reflux, what should be included? a. "Increase your intake of fat with each meal." b. "Lie down after eating to help your digestion." c. "Reduce your caloric intake to foster weight reduction." d. "Drink several glasses of fluid during each of your meals."

C! Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase the pressure; fluid should be discouraged with meals.

A daughter of a Chinese speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? a. Prejudice b. Stereotyping c. Assimilation d. Ethnocentrism

C! Assimilation involves incorporating the behaviors of the dominant culture. Maintaining eye contact is characteristic of the American culture and not Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

A nurse is teaching an older adult client about managing chronic pain with acetaminophen (Tylenol). Which client statement indicates that the teaching is effective? a. "I need to limit my intake of acetaminophen to 650 mg a day." b. "I can take oxycodone with the acetaminophen if it is ineffective." c. "I should take an emetic if I accidentally overdose on the acetaminophen." d. "I have to be careful about which over-the-counter cold preparations I take when I have a cold."

D! Many over-the-counter cold preparations contain acetaminophen; the amount of acetaminophen in cold preparations must be taken into consideration when the total amount of acetaminophen taken daily is calculated. A typical single dose is 650 mg a day for adults. Acetaminophen should not exceed 3 to 4 g a day, with a lower dose preferred in older adults. Taking oxycodone with the acetaminophen may result in an overdose. Oxycodone (Percocet) contains 325 to 650 mg of acetaminophen per dose, which should be calculated into the total grams of acetaminophen permitted daily. An emetic is contraindicated because it may reduce the client's ability to tolerate oral acetylcysteine, the antidote for acetaminophen toxicity.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? a. Stage I b. Stage II c. Stage III d. Unstageable

D! A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

A 4-month-old infant is to receive the second diphtheria/tetanus/pertussis (DTaP) immunization. The nurse reviews the infant's medical history before administering the vaccine. What information in the infant's history will influence the decision whether to administer the vaccine? a. Allergy to eggs b. Lactose intolerance c. Infectious dermatitis d. High fever after the first dose

D! A temperature of 105° F (40.5° C) or higher after a DTaP immunization is a contraindication to further DTaP immunizations. An allergy to eggs is not a contraindication to the administration of the DTaP vaccine because eggs are not used in the production of the vaccine. Lactose intolerance is not a contraindication to the administration of DTaP vaccine; nor is infectious dermatitis.

A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? a. Weak upper arm strength and impaired stamina b. Weight bearing as tolerated and unilateral paralysis c. Partial weight bearing on the affected extremity and kyphosis d. Strong upper arm strength and non-weight bearing on the affected extremity

D! A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

A nurse who is teaching a growth and development class to a group of parents at the daycare center explains that the toddler strives for a sense of: a. Trust b. Industry c. Initiative d. Autonomy

D! According to Erikson, the toddler strives for autonomy; most exploratory and negativistic behavior is based on the need to achieve this developmental task. Trust is the developmental task of the infant. Industry is the developmental task of the school-age child. Initiative is the developmental task of the preschool child.

The nurse is teaching hygiene practices to a 16-year-old patient who has recently had her first menstrual flow. Under which phase of development does the nurse classify the patient? a. Prepubescence b. Postpubescence c. Late adolescence d. Middle adolescence

D! Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20.

On the third postpartum day a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged? a. There is an overabundance of milk. b. Breastfeeding is probably ineffective. c. The breasts have been inadequately supported. d. The lymphatic system in the breasts is congested.

D! An exaggeration of venous and lymphatic circulation caused by prolactin occurs before lactation. Effective breastfeeding does not prevent engorgement; a lag between the production of milk and the efficiency of the ejection reflex often causes engorgement. Engorgement occurs before lactation or milk production. Inadequately support of the breasts does not cause engorgement, but support may relieve some of the discomfort.

A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub? Choose the appropriate location marked on the image. A. B. C. D.

D! Answer D is the lower-lateral chest, which is the area of greatest thoracic excursion. With visceral and parietal pleural inflammation (pleurisy), a low-pitched, coarse, grating sound is heard when the client breathes, particularly when approaching the height of inspiration. Bronchial breath sounds are heard over the trachea and at the nape of the neck on either side of the vertebrae. Bronchial sounds are loud, high pitched, and hollow, with a short inspiratory phase and long expiratory phase. Bronchovesicular breath sounds are heard on either side of the sternum or between the scapulae; bronchovesicular sounds have a moderate volume and medium pitch, with equal inspiratory and expiratory phases. C is the area where vesicular breath sounds are heard. Vesicular sounds are soft and low pitched, with a long inspiratory phase and a short expiratory phase; they are heard over most lung fields.

The parents of a school-age child tell the nurse, "My child seems very hot or red in the face, has abdominal pain, and appears jittery." What does the nurse suggest as the reason for the child's signs and symptoms? a. "The child may be staying up late at night to watch TV." b. "The child is growing up and feels the need for autonomy." c. "The child may be eating mostly junk food out of the house." d. "The child is experiencing stress in some area of the child's life."

D! Appearing hot or red in the face and jittery, along with abdominal pain, indicates that the child is experiencing stress. The parents need to talk about any stressors that the child is experiencing and should encourage the use of effective problem-solving and coping skills. Staying up late at night and watching TV may cause fatigue, but not abdominal pain or jitteriness. The school-age child does not seek autonomy and shares most things with the family. Eating junk food out of the house may result in obesity or unhealthy eating habits.

A nurse withholds a prescribed opioid medication from a client with intractable pain because the nurse fears the client will become addicted. In this situation the nurse is adhering to the ethical principle of: a. Veracity b. Autonomy c. Paternalism d. Beneficence

D! Beneficence commonly is referred to as "doing of good"; it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety. Unfortunately in this situation the client's priority is relief from pain and the nurse should be working with other health team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are made. Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices.

A nurse is teaching a mother about the immunization schedule for her baby. Between which months of age should the measles vaccine be given? 2 and 5 b. 6 and 8 c. 9 and 11 d. 12 and 15

D! Between 12 and 15 months is the optimal age because maternal antibodies to measles are no longer present to block the formation of the child's own antibodies. The measles vaccine is not given between 2 and 5 months, between 6 and 8 months, or between 9 and 11 months because of the questionable efficacy of the vaccination, due to the presence of maternal antibodies.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: a. Promoting analgesia and circulation b. Numbing the nerves and dilating the blood vessels c. Promoting circulation and reducing muscle spasms d. Causing local vasoconstriction, preventing edema and muscle spasm

D! Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasm. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels.

After teaching a client about a low fat diet, it is most important for the nurse to document: a. Client's receptiveness to the education. b. Family members/significant others were educated as well as the client. c. Client's weight loss goals. d. Client's ability to plan a low fat meal.

D! Documenting that client's ability to plan a low fat meal demonstrates the client's ability to apply the education to their lifestyle. Clients can be receptive to education but not understand it. It helps to include family members or significant others in the education. However, it is most effective if the clients themselves take ownership of their health care plan. Not all clients on a low fat diet need to lose weight.

A nurse teaches the parents of a 4-year-old child who is to receive digoxin (Lanoxin) elixir at home about the basic principles regarding its administration. What statement indicates to the nurse that they need further teaching? a. "We'll brush his teeth after each dose." b. "We won't mix the digoxin with fluids and foods." c. "We shouldn't give an additional dose if he vomits." d. "We should give the digoxin twice a day, at breakfast and dinner."

D! Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.

A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What instruction should the nurse include in the accident-prevention teaching plan? a. Remove small objects from the floor. b. Cover electric outlets with safety plugs. c. Remove toxic substances from accessible areas. d. Test the temperature of water before bathing.

D! Excessively high temperatures can damage the delicate skin of an infant. Although infants are capable of putting small things in their mouths, they are not yet able to crawl and probably will not be placed on the floor. At 3 months of age infants are not yet able to explore the environment to the point that electric outlets pose a problem. At 3 months of age infants are still too small and have not yet developed motor capabilities to get into containers of poison.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? a. Presence of distention b. Extent of weight gained c. Amount of high-fiber food consumed d. Length of time this problem has existed

D! First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

The nurse is teaching a parent of a 2-year-old toddler how to administer ear drops. In what direction should the nurse teach the parent to gently pull the pinna? a. Forward b. Up and back c. Straight back d. Down and back

D! In children younger than 3 years of age the eustachian tube is shorter, wider, and more horizontal. Pulling the pinna down and back facilitates passage of fluid, by way of gravity, to the eardrum. Pulling the pinna forward does not help position the canal for passage of the drops to the eardrum. Pulling the pinna up and back is the technique used for administering ear drops to children older than 3 years of age and adults. Pulling the pinna straight back does not position the canal for passage of the drops to the eardrum.

A nurse confirms that a 9-month-old infant's immunization schedule is up to date. Which immunization will the infant receive at 15 months of age? a. Hepatitis B (HepB) b. Polio vaccine c. Tetanus toxoid d. Measles, mumps, and rubella (MMR)

D! It is recommended that infants be given the MMR combination vaccine at 12 to 15 months of age. The first dose of HepB vaccine is given at birth, the second 4 weeks later, and the third 24 weeks after the second dose. The inactivated poliovirus vaccine (IPV) is given at 2 months, 4 months, and 6 to 18 months of age; the next booster (fourth) is given at 4 to 6 years of age. Tetanus toxoid is given at 2 months, 4 months, and 6 to 18 months of age; the next booster (fourth) is given at 4 to 6 years of age.

While discussing immunizations with the nurse, the father of a 7-month-old boy states, "You know, my son doesn't sit up by himself yet. Shouldn't he be able to do this by now?" How should the nurse respond? a. "He may need a little encouragement. How have you tried to help him sit up?" b. "Most babies do sit up by this time. Have you discussed this with the pediatrician?" c. "Don't worry that he's not sitting up yet. Some babies take longer to develop this skill." d. "Many babies don't sit up until they're 8 months old. Let's watch what he does when I sit him up."

D! Most infants by 6 months of age can remain in the sitting position when placed there; however, they do not sit up by themselves until 8 months. This response involves the parent in the assessment of the infant's capabilities. Stating that the child may just need encouragement questions the father's ability to assist the child and demeans the infant. Indicating that most babies are sitting up by this age is erroneous; many healthy infants do not sit steadily without support until 8 months of age. Telling the father not to worry cuts off communication and offers no directions to the father, who obviously is worried.

The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? a. "A newborn's spleen can't produce efficient antibodies." b. "Infants younger than 2 months are rarely exposed to infectious disease." c. "The immunization will attack the infant's immature immune system and cause the disease." d. "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

D! Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. The spleen does not produce antibodies. Infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. The nurse receiving report should first: a. Suggest that an antiemetic be prescribed b. Change the feeding schedule to omit nights c. Request that the type of solution be changed d. Gather more data from the night nurse about the technique used

D! Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance to tube feedings. Although suggesting that an antiemetic be prescribed may be done eventually, the feeding technique should be assessed first. Feedings generally are tolerated better if given frequently in small amounts over the entire 24 hours. Although changing the feeding schedule to omit nights and requesting that the type of solution be changed may be done eventually, the feeding technique should be assessed first.

A construction worker sustains a puncture from a rusty nail. It is unknown when the worker had the last immunization for tetanus and the primary health care provider prescribes tetanus immune globulin. What protection does this type of immunization offer? a. Lifelong passive immunity b. Long lasting active protection c. Stimulation of antibody production d. Immediate passive short term immunity

D! Tetanus immune globulin contains ready-made antibodies and confers short-term passive immunity. Passive immunity lasts a short time, not throughout life. Immune globulins confer passive artificial immunity, not long lasting active immunity. Immune globulins are antibodies; they do not stimulate the production of antibodies.

While reviewing the admission assessment the nurse finds that a 2-year-old child has not received immunization for measles, mumps, and rubella (MMR). At what age should the child have received this vaccine? a. 2 months b. 4 months c. 6 months d. 12 months

D! The MMR vaccine provides maximal protection against these diseases when the first dose is administered between 12 and 15 months of age. At 2 months of age the first immunizations against diphtheria, tetanus, pertussis (DTaP), and polio are given. At 4 month of age the second doses of the DTaP and polio vaccines are given. At 6 months of age the third dose of the DTaP vaccine is given.

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should: a. Give the vaccine b. Administer aspirin with the vaccine c. Hold the vaccine and notify the health care provider d. Reschedule administration of the vaccine for the next month

D! The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a febrile illness. Administering an aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary.

A nurse is teaching the parents of an 18-month-old child the procedure for instilling ear drops. How should this procedure be done? a. By cleansing the ear canal before instilling the drops b. By applying medicated ear wicks after instilling the drops c. By pulling the pinna up and back after drop instillation to promote dispersement of the drops d. By pulling the pinna down and back to straighten the auditory canal before instillation of the drops

D! The canal curves upward in children younger than 3 years of age; pulling the pinna down straightens the canal so medication will reach the eardrum. The ear canal is not cleansed before ear drops are instilled; this could exacerbate the infection. Applying ear wicks is contraindicated because it increases pressure within the ear. Pulling the pinna up and back after instillation of drops is unnecessary; pressing on the tragus several times will help disburse the drops.

A nurse is caring for a client who was admitted with failure to thrive and severe muscle wasting due to malnutrition and immobility. When the nurse administers pills to the client, the client is not capable of holding the medicine cup. What technique should the nurse utilize to facilitate Physiological Aspects of Care? a. Contact the client's health care provider. Ask to substitute a liquid form of medication for the pill form. b. Remove one pill at a time from the medicine cup and place it into the client's mouth. c. Crush the pills and administer with applesauce or ice cream. d. Ask the client how many pills the client wants to take at one time. Drop them from the medication cup directly into the client's mouth.

D! The client needs a physical assistance with Physiological Aspects of Care and therefore the nurse should help get the pills into the client's mouth while maintaining medical aseptic technique by using the medication cup and prevent aspiration by asking client how many pills the client would like to take at once. The client does not have difficulty swallowing and therefore substitution of pills by the liquid form of medication or crushing of pills is not necessary. Putting pills into the client's mouth by the hand is not safe for the nurse and violates medical asepsis; the choice does not mention that the nurse has gloves on.

A client in a hospice home care program is experiencing severe pain. Morphine (MS Contin) has been prescribed for pain management. Which information should the nurse plan to explain to the client in preparation for this pain management regimen? a. Drug addiction is a concern with this drug b. Request the medication before the pain becomes severe c. Intermittent administration of the drug is possible after an intermittent lock is inserted d. Dosages of the drug will be given automatically at regular intervals around the clock

D! The drug will be given routinely to maintain a continuous therapeutic blood level to keep the terminally ill client comfortable. Addiction is not a major concern for the terminally ill client. The client should not have to request this medication; it should be given regularly. Morphine is not administered intermittently; usually, it is prescribed in liquid form and is taken orally when administered in the home.

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? a. Tell the family to remove and dispose of the patch. b. Leave the patch in place for the mortician to remove. c. Have the family return the patch to the pharmacy for disposal. d. Remove and dispose of the patch in an appropriate receptacle.

D! The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

The mother of a 6-week-old infant asks the nurse at the pediatric clinic why, with the exception of hepatitis B, her baby's immunizations will not be started until the infant is 2 months old. How should the nurse respond? a. Vaccines cause disease in younger infants' bodies. b. Younger infants rarely are exposed to infectious diseases. c. Insufficient antibodies are produced by younger infants' spleens. d. Maternal antibodies interfere with younger infants' antibody production.

D! The passive antibodies to the organisms that cause diphtheria, tetanus, and pertussis received from the mother have diminished by 8 weeks of age and no longer interfere with the development of active immunity after this age. Vaccines contain attenuated viruses; they may cause irritability and fever, but they do not cause the related disease. Infants are exposed to infectious diseases; passive immunity from the mother offers some protection. The spleen does not produce antibodies.

An 18-month-old toddler who has received the appropriate immunizations on time is visiting the pediatric clinic for the next scheduled immunization. What vaccine should the nurse administer? a. Second hepatitis B (Hep B) vaccine b. Fifth inactivated polio vaccine (IPV) c. First pneumococcal vaccine (PCV) and influenza vaccine (Hib) d. Fourth diphtheria toxoid, tetanus toxoid, and acellular pertussis (DTaP) vaccine

D! The recommended age for the fourth dose of DTaP is 15 to 18 months. The recommended age for the second dose of Hep B is 4 weeks after the first dose, which is given immediately after birth. Four, not five, doses of IPV are recommended. The initial doses of PCV and Hib are given at 2 months

A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when collecting this specimen from a urinary retention catheter? a. Disconnect the catheter and drain the urine into a clean container. b. Clean the drainage valve and remove the urine from the catheter bag. c. Wipe the catheter with alcohol and drain the urine into a sterile test tube. d. Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.

D! The urinary catheter and drainage bag should always remain a closed sterile system; urine should be drawn only from the catheter port, not the collection bag. Cleaning the drainage valve and removing the urine from the catheter bag will not yield a fresh specimen indicating present acetone levels. The system should remain closed so that fewer microorganisms enter the urinary tract.

A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiological characteristic should the nurse include? a. Periodic exacerbations b. Aggressive acting-out behavior c. Hypoxia of selected areas of brain tissue d. Areas of brain destruction called senile plaques

D! When an older person's brain atrophies, some unusual deposits of iron are scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called senile plaques, can be found; these plaques represent the end stage of destruction of brain tissue. Periodic exacerbations are associated with chronic deterioration, not with remissions and exacerbations. Aggressive acting-out behavior may or may not be part of the disorder. Hypoxia of selected areas of brain tissue is typical of vascular dementia, not dementia of the Alzheimer type.

A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) indicates a need for further teaching? a. "I will wash my hands before entering and leaving the room." b. "I will put on gloves and a gown before entering the room." c. "I will leave a thermometer, blood pressure cuff, and stethoscope in the room for use for this client only." d. "I will remove the gown, then the gloves, before washing my hands."

D! When removing personal protective equipment (PPE), the gloves should be removed before the gown, and then the hands should be washed. Contact precautions require the use of a gown and gloves. Hands should be washed before and after every client contact. Equipment should be dedicated for use only by the client in contact isolation.

The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? a. Dietary practices b. Concept of space c. Immigration status d. Role within the family

D! If an Asian-American client tells the nurse that she adheres to traditional Asian practices, the nurse must recognize that the family is the central and most important social force acting on the individual. Dietary practices, concept of space, and immigration status are not as significant as family dynamics.

Which nursing activities are examples of primary prevention? Select all that apply. a. Preventing disabilities b. Correcting dietary deficiencies c. Establishing goals for rehabilitation d. Assisting with immunization programs e. Facilitating a program about smoking cessation

D&E! Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.

A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child? a. Opening the tube 1 hour before feeding b. Keeping the child lying flat during the feeding c. Flushing the tube with normal saline after the feeding d. Positioning the child on the right side after the feeding

Positioning the child on the right side after feeding facilitates digestion because the pyloric sphincter is on this side and gravity aids emptying of the stomach. The feeding may be started immediately after the tube is opened. Keeping the child lying flat during the feeding may result in aspiration; the child's head and torso should be elevated. If the gastrostomy tube is flushed before or after a feeding, water, not normal saline, is used.

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.

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. Correct Answer: D

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.

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. Correct Answer: 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.

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. Correct Answer: B

A client with a spinal cord injury tends to assume the low-Fowler position excessively. What area of the body is most vulnerable to the development of a pressure ulcer in this client?

The Sacrum The sacrum bears the most pressure because it is the focal point of the weight of the body when in the low-Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low-Fowler position.

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C

A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?

The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150

The health care provider prescribes nitroglycerin ointment to be applied topically every eight hours for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? "I may experience: a. A headache." b. Increased blood pressure readings." c. A slow pulse rate." d. Confusion."

The most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects are tachycardia, not bradycardia; hypotension, not hypertension; and dizziness, not confusion.

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.

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. Correct Answer: B

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B