Missed Practice Questions

The nurse is evaluating the lifestyle modifications a client has made to prevent gastroesophageal reflux. Which statement indicates that the client understands how to prevent reflux?

"I try to eat smaller amounts of food more often throughout the day." --To prevent gastric distention and gastroesophageal reflux, the client is encouraged to eat smaller, more frequent meals.

A client has signed a document indicating a wish not to be resuscitated. During morning rounds, the nurse finds the client without vital signs. What is the most appropriate action for the nurse to take?

Notify the physician that the client has no vital signs.

The nurse is walking past the supply room on the hospital unit and sees smoke coming out from below the door. Opening the door, the nurse sees flames. Identify the correct sequence of the nurse's response. All options must be used.

Remove from the area anyone who is in immediate risk of harm. Activate the fire alarm. Contain the smoke and fire by closing windows, doors, and curtains. Evacuate the area or extinguish the fire, as appropriate to the severity of the fire.

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply.

Repeat the prescription to the HCP. Ask the HCP to confirm that the prescription is correct as understood by the nurse. --nurse should write the prescription, read the prescription back to the HCP, and receive confirmation from the HCP that the prescription is correct

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing?

decreased mental status --Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma.

A nurse is caring for a client admitted to the inpatient psychiatric unit. When is it most important to introduce information about the end of the nurse-client relationship?

during the orientation phase --Preparation for ending the nurse-client relationship should begin during the orientation phase, when realistic limits of the relationship are established

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client?

Ask family members to wash their hands frequently. --The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order?

Ask the physician to prescribe a specific laxative. --The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. What information should the nurse give the spouse about cleaning the wound?

Clean both sites independently. --treated as separate sites to avoid cross contamination

The client is admitted to the obstetrics unit of the hospital for induction of labor at 41 weeks gestation. The nurse administers oxytocin IV and determines that the oxytocin has been effective after which statements by the client? Select all that apply.

"The health care provider told me that my cervix has changed from 1 cm to 2 cm in the last hour." "I am feeling contractions now." --After initiation of oxytocin, the client may report now feeling the contractions or that the oxytocin has improved uterine contraction, and that after vaginal examination, the cervix has opened 1 cm or more within 1 hour

The nurse is performing an assessment of a client admitted to the behavioral health unit with schizophrenia. Which behavior by the client would the nurse document as positive symptoms? Select all that apply.

Client states, "I am the King of England!" Client is copying the movements of the client sitting next to them. Client states, "Do you see all of the rats crawling on the floor? Kill them!" --positive symptoms of schizophrenia include delusions or false beliefs that are not based in reality, echopraxia is an imitation of the movements and gestures of another person whom the client is watching. Hallucinations are common positive symptoms

A married male client is admitted to the psychiatric unit. During the nurse's interview the client states, "I cannot live this lie anymore. I wish I were a woman. I cannot live one more day feeling this way." What is the nurse's priority intervention?

Encourage the client to talk about his feelings. --This client reveals that he is under severe stress with potential suicidal ideation that needs to be further explored. The nurse should establish if the client has a plan for self-harm that would warrant suicide precautions prior to imitating these precautions.

After assessing the blood pressure of a client with a diagnosis of catatonia, the client's arm remains outstretched in an awkward position. Which of the following is the correct action by the nurse?

Reposition the client's arm. --The nurse should reposition the arm as the client is exhibiting waxy flexibility.

A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse?

Take them to the decontamination area. --The best action by the nurse is to take the clients to the decontamination area to be decontaminated. That way the agent is no longer infiltrating the clients nor are the other individuals in the emergency room exposed to the decontaminating agent

A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address her concerns? Select all that apply.

Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. Report the behaviors to the unit manager for further investigation. --The nurse should talk to the suspected nurse and report to management. It should not be discussed with others on the unit. It is not appropriate to wait until something happens.

A client with a terminal illness is unconscious. The client's spouse wants the client's status to be full code. The client's sibling, who is the durable power of attorney and healthcare proxy, insists that the client's status should be do not resuscitate (DNR). Which person has legal precedence?

The sibling's wishes are legally binding. --The durable power of attorney for health care takes legal precedence. It is often recommended that this role be given to someone objectively distanced from the client.

A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy?

alanine aminotransferase and aspartate aminotransferase --Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase.

The nurse plans to administer an injection of heparin to a client. Which technique for heparin administration is appropriate? The nurse:

applies gentle pressure to the site for 5 to 10 seconds after the injection. --Gentle pressure should be applied after the injection, but the area must not be massaged. A 25- or 26-gauge, ½- to 5/8-inch (1.3- to 1.6-cm) needle is most appropriate for heparin administration.

A client diagnosed with uncomplicated rheumatoid arthritis is receiving naproxen. Which medication would require further intervention by the nurse prior to administration?

dabigatran --Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used for clients with rheumatoid arthritis. NSAIDs are aspirin and aspirin-like medications that may increase the risk of bleeding when taken with an anticoagulant like dabigatran.

The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). What additional signs should the nurse assess?

deep vein thrombosis (DVT) in the left leg.

A client recovering from a drug overdose is interacting with the nurse and recounting her exploits at numerous parties she has attended. Which action is most therapeutic?

directing the conversation to realistic concerns --The nurse directs the conversation to realistic concerns or issues to decrease denial and focus on rebuilding a substance-free life.

Which statement indicates that the client with diabetes insipidus understands how to manage care?

maintain normal fluid and electrolyte balance. --Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client.

A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?

oxytocin 30 units in 500 ml D5W --A Bishop score evaluates cervical readiness for labor based on five factors: cervical softness, cervical effacement, dilation, fetal position, and station. A Bishop score of 5 or greater in a multipara or a score of 8 or greater in a primipara indicate that a vaginal birth is likely to result from the induction process. The nurse should expect that labor will be induced using oxytocin because the Bishop score indicates that the client is 60% to 70% effaced, 3 to 4 cm dilated, and in an anterior position. The cervix is soft and the presenting part is at a -1 to 0 position. Prostaglandin gel, misoprostol, and dinoprostone are all cervical ripening agents, and the doses are accurate; however, cervical ripening has already taken place.

The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?

pulmonary embolism --Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time.

How soon after chlorpromazine administration should a nurse expect to see a client's delusional thoughts and hallucinations eliminated?

several weeks --Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may not appear until several weeks after the start of therapy.

Diphenoxylate/atropine has been prescribed to treat a client's diarrhea. The nurse should teach the client to report:

urine retention --Diphenoxylate/atropine has anticholinergic properties. Common side effects include urine retention, blurred vision, constipation, palpitations, nervousness, and decreased sweating.

What is the most important assessment for the nurse to make when administering tamsulosin to a client with benign prostatic hyperplasia (BPH)?

voiding pattern --The alpha-adrenergic blocker tamsulosin relaxes the smooth muscle of the bladder neck and prostate, so the urinary voiding symptoms of BPH are reduced in many clients.

The nurse is assisting with a birth to a multigravida in active labor who is not having anesthesia. The client's cervix is completely dilated. When should the nurse coach the client to push?

when she has an urge to push --The best approach is to allow the client to push when she feels the urge to push with a contraction. When the contraction begins, the client may have an immediate urge to push, or it may take time for fetal descent to stimulate stretch receptors

A client with a positive Mantoux test result is taking isoniazid (INH) and rifampin (RIF) for an initial treatment over a 2-month period for confirmed tuberculosis. The nurse should assess specifically for which finding during the clinic visit?

yellowing of the skin or eyes --Clients who are taking these medications need to be closely monitored for jaundice or yellowing of the sclera.

A nurse is caring for a client following a tonsillectomy and fails to routinely assess the back of the client's throat for signs of bleeding. The nurse manager reviews the client's chart and notices the omission of the assessments. Which is the best response to the nurse regarding the missing assessments?

"Failure to complete these assessments constitutes negligent behavior." --By not checking the back of the throat for bleeding after a tonsillectomy, the nurse is negligent.

A newer nurse is working on a medical-surgical unit that frequently admits clients with issues that may cause ethical dilemmas. Which situation(s) would be appropriate for the nurse to forward for ethics committee review? Select all that apply.

A confused client with cancer has an advance directive that indicates a wish for cardiopulmonary resuscitation, but the client's 4 children all want a do-not-resuscitate (DNR) order. A 16-year-old client wants a blood transfusion, but the parents are refusing consent on religious grounds. A client who is on the lung transplant list was recently seen smoking.

A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. What should the nurse instruct the client to do?

Avoid activities that elicit the Valsalva maneuver. --in order to reduce bleeding and stress on suture lines.

Diagnosis of myasthenia gravis is confirmed by evaluating the client's response to an intravenous injection of the cholinesterase inhibitor edrophonium. If the client responds positively, what would the nurse expect?

a rapid and dramatic increase in muscle strength --With I.V. administration of a cholinesterase inhibitor, edrophonium, the individual should have a rapid recovery of muscle strength. Often there is a dramatic increase in muscle strength, which helps confirm the diagnosis of myasthenia gravis

The home health nurse is visiting a client newly diagnosed with type 1 diabetes mellitus. The client reports nausea and abdominal pain. The nurse observes dehydration and dry skin. What question should the nurse ask the client?

"Are you taking your insulin daily?" --The nurse should ask if the client is taking their insulin, as a common cause of DKA is missed insulin. Classic symptoms of diabetic ketoacidosis (DKA) include polyuria, weight loss, nausea and vomiting, altered mental status, abdominal pain, and Kussmaul respirations.

A client at 33 weeks' gestation is leaking amniotic fluid. She is placed on an external fetal monitor. The monitor indicates uterine irritability, and contractions are occurring every 4 to 6 minutes. The provider orders nifedipine 20 mg po now and every 8 hours until birth or contractions cease. What is the most important information for the nurse to teach this client concerning nifedipine?

"You may experience nausea and some dizziness." --Common side effects of nifedipine are feelings of dizziness, nausea, and headach

A client presents to the emergency department (ED) with reports of a "skipped beat" in their chest. The health care provider diagnoses premature ventricular contractions (PVCs) and orders quinidine sulfate. What should the nurse include in the client's teaching concerning the administration of quinidine sulfate? Select all that apply.

"You should take quinidine sulfate with food." "You should report palpitations and breathlessness when taking quinidine sulfate." "You should avoid alcohol when taking quinidine sulfate." "You should take your blood pressure reading before taking quinidine sulfate." --Quinidine is an antidysrhythmic, and client teaching will include monitoring heart rate and respiratory status. The client should take this medication with food to avoid adverse GI reactions. Drinking grapefruit juice decreases the absorption of quinidine sulfate. Like most medications, quinidine sulfate should not be taken with alcohol.

A community health nurse is involved in a teaching program to help prevent rheumatic fever in school-age children. Which is the most important intervention to decrease the incidence of the disease?

teaching clients to seek medical treatment for streptococcal pharyngitis --Early detection and treatment of streptococcal infections help prevent the development of rheumatic fever

A client's spouse has expressed great concern about the fact that antibiotics have been prescribed for the treatment of pneumonia. The spouse states, "I do not trust all these pharmaceuticals. We are going to treat the pneumonia using the magnet therapy I read about online." What is the nurse's best response?

"It sounds like you have some important questions about the use of medication." --When clients present information that is inaccurate or unfounded, the nurse should use this opportunity to discuss the client's doubts and reservations. The nurse needs to obtain more information

The nurse is assessing a client who is distraught after receiving a positive diagnosis for human immunodeficiency virus (HIV). The client states, "I am not ready to die." What is the nurse's best action?

Acknowledge the client's fears, and then explain the increasing survival times in HIV.

A nurse is about to give a full-term neonate their first bath. How should the nurse proceed?

Bathe the neonate only after vital signs have stabilized. --To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized

A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which intervention would the nurse do first?

Check the status of the fetal heart rate. --The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse's first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor.

A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral arterial disease. The health care provider (HCP) started the client on pentoxifylline once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first:

Inform the HCP. --Angina is an adverse reaction to pentoxifylline, which should be used cautiously in clients with CAD. The nurse should report the client's symptoms to the HCP , who may prescribe nitroglycerin and possibly discontinue the pentoxifylline

A nurse is reviewing a client's medical record and notes that the health care provider has prescribed furosemide 400 mg orally twice a day. What will be the best action by the nurse?

Notify the health care provider about the concern for the prescribed dose. --The nurse is responsible for clarifying any prescription for a medication prescribed outside the normal dose. The usual dose for furosemide is 20 to 80 mg. Therefore, the nurse needs to contact the health care provider to ensure what has been prescribed is indeed correct.

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)?

Restrict staff and visitors with active infections.

A middle-aged female with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which action should the nurse suggest?

See the health care provider immediately. --Redness, warmth, and swelling are all signs of infection. Treatment with antibiotics is usually indicated. Infection usually increases fluid accumulation and could worsen the lymphedema. Warm compresses could also increase fluid accumulation

A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents?

Wash the buttocks using mild soap. --buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal?

high-pitched cry --Manifestations of opiate withdrawal in the neonate, known as neonatal abstinence syndrome (NAS), include an increased central nervous system irritability, gastrointestinal symptoms, and metabolic, vasomotor, and respiratory disturbances

A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action?

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis --This combination of symptoms indicates hypoxia.

A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

methadone --it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as opiates such as heroin and morphine or stimulants such as cocaine

The chart entry for a client with a fungal infection in the maxillary sinus readsProgress notes10/15/161530Client reports increased nasal discharge, a productive cough with green discharge, and increasing facial pain 60 minutes after pain medication was given. Recent vital signs: Temperature 98.2° F (37° C), Pulse 120, and Respirations 26.What is the priority nursing action?

obtain a sputum sample --The nurse should obtain a sputum sample and document the color and consistency of the discharge. The provider would indicate if the sputum needs to go to the lab for analysis.

The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea?

supine --In the supine position, the abdominal contents press against the diaphragm, impeding expansion of the lungs. The other choices are correct to assist with ease of breathing.

In which phase of postpartum psychological adaption would discharge teaching regarding infant care most likely be successful?

taking hold --Beginning after completion of the taking-in phase, the taking-hold phase lasts about 4 to 5 weeks. At this time, the client is most ready to learn self-care and infant care skills.

A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?

untreated hypertension

The nurse is assigned a client with end-stage ovarian cancer with recurrent ascites, and the client is to undergo paracentesis. Which activity is best to delegate to an experienced licensed practical nurse (LPN/VN)?

vital signs every 15 minutes after the paracentesis --An experienced LPN/LVN would monitor and report vital signs to the RN. The paracentesis tray can be obtained by the unit clerk or unlicensed assistive personnel (UAP). The admission assessment and teaching require the RN's expertise and education.

A client has sought care because she has recently returned from a trip to Central and South America and is concerned that she might have contracted the Zika virus. What question should the nurse prioritize during the client interview?

"Is there any chance that you might be pregnant?" --Infection with the Zika virus is associated with an increased risk of microcephaly. There is no vaccine, and it is spread by mosquitos; being on a farm or ranch is not a risk factor

The nurse is managing the care for a client in a disaster shelter who broke a femur and has lost her family home in a hurricane. What measures should the nurse take? Select all that apply.

Supervise the care provided to the client during the crisis. Act as a client advocate for the client in crisis. Discuss with the interdisciplinary team available community resources for the client. Obtain accurate identification including name, age, address, contact information, and names of relatives.

A client with congestive heart failure and spouse are planning a trip to visit their grandchildren who live out of state. What recommendation should the nurse provide to the client regarding traveling with medications? Select all that apply.

Take extra medication in case the trip is extended. Carry a list of the medications and health care provider's phone number. Keep medications in carry on luggage if traveling by plane.

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which actions should the nurse take before starting the NG feeding on the child? Select all that apply.

Verify the physician's order. Check placement of the NG tube. Assess for bowel sounds. --no more than a 4-hour supply should be hung to prevent the growth of microorganisms.

The nurse is caring for a child with a newly diagnosed allergy to latex. List, in order of priority, the nursing interventions for this client.

assessment of respiratory effort assessment of heart rate and blood pressure assessment of skin education of the family -- According to Maslow's hierarchy, physiological needs must be met first and a basic need for oxygenation and perfusion comes first. Oxygenation has a higher priority than perfusion. Skin integrity would be next, and then, knowledge deficit.

What would be an environmental cue that the nurse should use to assist a cognitively impaired client with dementia?

client's name on the bedroom door --Examples of environmental cues include names on bedroom doors and the use of clocks and bulletin boards with the month, day, and year

The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should most avoid?

rock climbing --A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing

The student nurse asks why a client is receiving an I.V. of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse?

With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. --In diabetic ketoacidosis, the cellular buffers will be activated. Potassium will move out of the cell and hydrogen will move inside the cells to lessen the impact on the plasma pH. Once the acidosis is corrected by bicarbonate injections and I.V. lactated Ringer's, potassium will move back into the cells, resulting in hypokalemia. Potassium levels will be monitored closely, and replacement will be initiated. Lactated Ringer's helps increase the blood pH and provides a source of bicarbonate replacement to replenish the base portion of the 1:20 acid-to-base relationship that helps maintain the blood at the pH of 7.35 to 7.45. Sodium does not switch with potassium in an acidotic state.

A client who is taking olanzapine states he is being poisoned and refuses to take his scheduled medication. The nurse states, "If you don't take your medication, you'll be put into seclusion." The nurse's statement is an example of which legal concept?

assault --The nurse's statement exemplifies assault, which is the threat of being touched in an offensive way without consent.