Nclex Cris 2-50

In early October, a home health nurse makes a home visit to an older client diagnosed with cataracts who is scheduled to have cataract removal with a lens implant in mid-November. Which of the following recommendations by the nurse is MOST important? 1. "Notify a trusted neighbor that you will be gone overnight." 2. "Get a flu shot as soon as possible" 3. "Read this information about surgical removal of cataracts." 4. "Check with your insurance company regarding co-payment and services."

Strategy: "MOST important" indicates priority. 1) usually performed on an outpatient basis, with discharge usually 2 hours after surgery 2) CORRECT— flu can cause client to sneeze, cough, or blow nose, which would increase intraocular pressure; flu shot helps prevent occurrence of flu 3) promoting wellness takes priority 4) is important; but client's physical well-being takes priority

A patient is to be discharged after a right total hip replacement. Which of the following statements, if made by the patient to the nurse, indicates that teaching has been effective? 1. "I can't sit in my favorite recliner with my legs up." 2. "I should ask my wife to put on my socks and shoes." 3. "I should clean the incision with a mixture of hydrogen peroxide and water before applying a sterile dressing." 4. "I don't need to continue to do the leg exercises I learned in the hospital."

Strategy: Thank about what the patient's words mean. 1) can sit in recliner as long as hip flexion is less than 45 to 60°; avoid stooping; do not sleep on operative side until directed to do so 2) CORRECT— this self-care activity would cause hip flexion greater than 40 to 60°, might cause dislocation of hip; maintain abduction; do not cross legs 3) not needed, should use soap and water 4) should continue to do exercises

While sitting at the front desk completing an assessment sheet, a new graduate nurse asks the nursing assistant to perform a finger stick blood sugar for the assigned client. The nursing assistant responds, "Why can't you do it?" Which of the following responses by the nurse is BEST? 1. "Please page me when you have completed the task." 2. "It is important that the blood sugar be completed now." 3. "Why did you ask that?" 4. "If you don't have time, I will ask someone else to do it."

Strategy: "BEST" indicates discrimination is required to answer the question. 1) CORRECT— performing a finger stick is within the scope of practice of the nursing assistant and the task should be carried out as delegated 2) nurse not required to explain assignment 3) nontherapeutic; leads to further discussion, which is not appropriate 4) example of reverse delegation, lower person on hierarchy delegates to person higher on the hierarchy

The nurse performs an assessment for a client diagnosed with bilateral cataracts. To determine the amount of visual impairment experienced by the client, which of the following questions by the nurse is BEST? 1. "Would you please identify what you can see clearly?" 2. "How have your visual abilities changed?" 3. "When did you first notice that your vision had changed?" 4. "Would you please tell me what you have difficulty seeing?"

Strategy: "BEST" indicates discrimination is required to answer the question. 1) cataracts are partial or total opacity of the normally transparent crystalline lens and cause objects to appear distorted and blurred; nurse unable to estimate loss of vision with this question 2) question is too broad and difficult to understand 3) does not determine the client's current vision 4) CORRECT— this question helps the nurse determine client's current loss of vision

The nurse cares for a client diagnosed with hypertension and type 1 diabetes mellitus. The client complains to the nurse that the physician wants the client to discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril (Capoten) 50 mg PO tid. The client states, "It took a long time to find a medication that controls my blood pressure with minimal side effects, and I do not want to go through that again." Which of the following responses by the nurse is BEST? 1. "How many different antihypertensives did you try?" 2. "Captopril is the best drug for preventing or slowing down the destruction of your kidneys." 3. "Your physician is a specialist in this area and feels you need to change." 4. "Why not give it a try?"

Strategy: "BEST" indicates discrimination is required to answer the question. 1) focus on the here and now; not relevant how many different drugs the client tried 2) CORRECT— Capoten dilates the efferent arterioles, resulting in lowering the glomerular pressure; verapamil dilates the afferent arterioles, increasing the pressure 3) does not give the client a reason why the physician wants to change the medication 4) answer does not give the client any information

The mother of a 4-year-old tells the nurse she is worried because her daughter has begun to stutter. The mother asks the nurse what actions can be taken to stop the stuttering. Which of the following responses by the nurse is BEST? 1. "What has been happening in your child's life?" 2. "Reward your child when she speaks fluently." 3. "Instruct your child to start over and speak more slowly." 4. "Slow down your own speech and talk to your daughter calmly."

Strategy: "BEST" indicates discrimination is required to answer the question. 1) implies that something is wrong; broken fluency is a normal occurrence in preschoolers 2) because it is normal behavior, there is no reason to offer reward 3) will make child conscious of speech and increase the stuttering 4) CORRECT— does not call attention to the child's speech pattern and does gives the child time and space to respond; secondary stuttering is a normal phase of language development

A 16-year-old girl is brought to the emergency room by her parents for evaluation of an eating disorder. When the nurse approaches the client to draw a blood sample, the client cries out, "I hate having my blood drawn. Go away!" Which of the following responses by the nurse is BEST? 1. "What's the matter? Are you afraid of what we are going to find?" 2. "What is it about having your blood drawn that upsets you?" 3. "Take a deep breath. It will be over before you know it." 4. "I'll be back in 15 minutes so we can discuss your concern."

Strategy: "BEST" indicates discrimination is required to answer the question. 1) yes/no question; nurse is making an assumption 2) CORRECT— open-ended; relates to client's verbal and nonverbal communication and responds to the client's feelings 3) "don't worry" response; nontherapeutic 4) do not leave the client alone

The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It is MOST important for the nurse to clarify which of the following orders by the physician? 1. Furosemide (Lasix) 20 mg IV every 12 hours. 2. 2 g/day sodium diet 3. Normal saline at 125 ml/hour IV. 4. Oxygen at 2 L per nasal cannula.

Strategy: "Clarify an order" indicates an order that may harm the patient 1) appropriate order; loop diuretic that promotes the excretion of excess water; decreases blood volume and pressure in the left ventricle 2) appropriate order; because extracellular fluid is primarily regulated by sodium, a low-sodium diet may decrease excess water 3) CORRECT— because the patient may have excess fluid volume, may be on fluid volume restriction; weigh daily and measure I and O 4) appropriate order; may have impaired gas exchange and develop hypoxemia depending on the severity of heart failure

The nurse in the outpatient clinic performs an assessment of an elderly woman. The client states that her husband had a CVA 7 months ago, and she cared for him for 3 months. Four months ago she had to place her husband in a long-term care facility because she was no longer able to care for him. Since that time the client reports she has lost 40 pounds, she is afraid to live alone, and she sorely misses her husband. The nurse notices that the client is extremely hard of hearing. Which of the following suggestions should the nurse make FIRST? 1. "I think you should move to the nursing home with your husband." 2. "Have you considered installing a security system in your home?" 3. "I'm going to refer you to Meals on Wheels." 4. "Perhaps you should find a hobby or join a club for seniors."

Strategy: "FIRST" indicates priority. 1) assumes client is a candidate for a nursing home; loneliness is not a reason to move to a long-term care facility 2) addresses client's concern about safety and security; priority is making sure that the client eats 3) CORRECT— according to Maslow, take care of basic needs first 4) client's nutrition and safety take priority over psychosocial needs

The nurse cares for clients in the emergency department after an earthquake. Which of the following clients should the nurse see FIRST? 1. A client at 7 months' gestation complaining of cramping and blood-streaked discharge. 2. A client with a displaced fracture of the right radius with blood seeping from the wound. 3. A client complaining of lightheadedness; nurse notes client is clammy, pulse 112, respirations 28. 4. A client with type 1 diabetes who took insulin immediately before the earthquake and is complaining of lightheadedness.

Strategy: "FIRST" indicates priority. 1) may be in early labor, stable patient 2) illnesses that can wait up to 2 hours are considered urgent 3) CORRECT— client appears to be developing shock; most unstable client 4) lightheadedness probably due to hypoglycemia; more stable than client in shock

A terminally ill client with excruciating pain episodes complains the pain medication given at night does not relieve the pain as well as it does during the day. A chart review reveals that clients report pain medication being less effective, and the clients receive more medication when a particular nurse is working. Which of the following actions should the nurse take FIRST? 1. Set up a hidden camera in the medication room. 2. Ask physician to consider increasing the dosage of medication at night. 3. Determine how long the client has been receiving the medication. 4. Temporarily assign another nurse to give all of the PRN medications.

Strategy: "FIRST" indicates priority. 1) priority is caring for the client in pain 2) clients complaining of pain is an indication that there may be a problem with one of the nurses 3) assumes that client is experiencing a tolerance to the medication 4) CORRECT— primary focus is client comfort; validation of the nurse having a substance abuse problem does not override quality client care

The nurse on the medical/surgical unit admits an elderly client after the patient has undergone a below-the-knee amputation. The nurse obtains vitals signs and assesses that the client is able to be aroused but is sleepy. When the client awakens and realizes that the amputation was performed, the client begins to scream. Which of the following statements by the nurse is MOST appropriate? 1. "The physician informed you that the amputation was required." 2. "I'll get you some medication so that you can rest." 3. "Your family is waiting in the lobby to come see you." 4. "Since you seem upset, I'll stay with you."

Strategy: "MOST appropriate" indicates discrimination is required to answer the question 1) first step of readjustment of changed body image is psychological shock; client will not be receptive to receiving information 2) more important for the nurse to stay with the client 3) passing the buck; nurse should care for client 4) CORRECT— acknowledges client's feelings; nurse should stay with patient, focus on here and now, and deal with client's immediate problems

The nurse admits a client to the medical unit with a diagnosis of heart failure and pneumonia. The client's wife states that the client has recently experienced a significant decline in his hearing and is extremely depressed. Which of the following actions by the nurse is MOST appropriate? 1. Provide the client an opportunity to express his feelings about the hearing loss. 2. Assign the client to a nurse who has a hearing impairment. 3. Encourage the client to use the incentive spirometer every hour while awake. 4. Contact a support group for the hearing impaired.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) according to Maslow, physical needs take priority over psychosocial needs 2) intervention aimed at the hearing loss and depression; nurse needs to deal with physical needs first 3) CORRECT— pneumonia causes impaired gas exchange; incentive spirometry prevents or reverses atelectasis 4) initial interventions aimed at the pneumonia

The nurse cares for a client diagnosed with chronic obstructive pulmonary disease (COPD) receiving oxygen per nasal canula at 2 L/min. The nurse observes that the client has shortness of breath and chest pain. The nurse notifies the assigned physician, and the physician makes no changes in the amount of oxygen the client is receiving. Which of the following responses by the nurse is MOST appropriate? 1. Report concerns to the supervisor. 2. Contact the physician a second time. 3. Inform the family members that the physician has not changed the client's orders. 4. Continue to monitor the respiratory status of the client.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) client has symptoms of oxygen toxicity; hypoxemia is a greater threat than oxygen toxicity 2) hypoxemia is greater threat than oxygen toxicity 3) inappropriate action 4) CORRECT— nurse should continue to assess client's condition and report changes to the physician; hypoxemia is greater threat than oxygen toxicity

The charge nurse on the night shift receives a call from one of the nurses who is to report the next morning. The day-shift nurse reports that she has been diagnosed with strep throat and placed on antibiotics. Which of the following responses by the charge nurse is MOST appropriate? 1. "How long have you had the sore throat?" 2. "How long have you been on antibiotics?" 3. "Do you have an elevated temperature?" 4. "Do you have a doctor's release to work?"

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) duration of sore throat is not relevant to being able to work 2) CORRECT— after 24 hours of antibiotic therapy, strep throat is no longer contagious and a health care provider can resume responsibilities 3) fever is the body's reaction to disease as a defense mechanism; being afebrile is often a condition for being able to work but duration of antibiotic therapy is the best indicator 4) nurse does not need a physician's release in the case of strep throat

The community health nurse visits the home of a client with four school-aged children. The client is diagnosed with severely disabling migraine headaches. Which of the following instructions by the nurse is MOST appropriate? 1. "Hire someone to help with your children." 2. "Report excessive menstrual flow." 3. "Avoid stressful situations." 4. "Go to bed at the same time every night."

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) may or may not be feasible for client; requires further assessment before making this suggestion 2) fluctuating estrogen levels have been related to migraine headaches, but the amount of flow does not appear to be related 3) triggers include eating chocolate or cheese, drinking coffee, and going for long periods of time between meals 4) CORRECT— fatigue is a trigger

The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg OD. The client tells the nurse that he has been experiencing insomnia the last couple of weeks. Which of the following responses by the nurse is MOST appropriate? 1. "The physician may have to decrease the dose of medication." 2. "Tell me about your bedtime routine." 3. "When do you take the medication?" 4. "Take a warm bath before going to bed."

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. 1) should assess before implementing 2) assessment; more important to determine when client is taking the medication 3) CORRECT— should take medication before breakfast to prevent insomnia 4) assumes that medication is not the cause of the insomnia

The nurse cares for a client receiving cholestyramine (Questran) 4 g BID. The nurse would be MOST concerned if the client makes which of the following statements? 1. "I have a hard bowel movement every 2 or 3 days." 2. "I sprinkle the powder on my orange juice at breakfast." 3. "I have increased my intake of milk and green leafy vegetables." 4. "I take digoxin (Lanoxin) at lunch every day."

Strategy: "MOST concerned" indicates incorrect information. 1) CORRECT— constipation is a side effect of medication; encourage diet high in fiber and fluids 2) sprinkle on liquid, let stand for a few minutes, and stir thoroughly; after drinking, add a small amount of liquid to same glass, mix, and drink to ensure intake of entire dose 3) medication depletes fat-soluble vitamins; milk contains vitamins A and D; green leafy vegetables contain vitamins E and K 4) take other medication one hour before or 4 to 6 hours after taking Questran

A 75-year-old client is brought by his wife to the outpatient clinic. The nurse notes that the client has a 10-year history of chronic renal failure and has been taking cimetidine (Tagamet) for two weeks. It is MOST important for the nurse to investigate which of the following statements made by the client's wife? 1. My husband has been complaining that his bowel movements are hard to pass. 2. My husband takes his Tagamet just before he eats his meals. 3. My husband seems to be having more trouble with his memory lately. 4. My husband sometimes has a headache after reading the newspaper.

Strategy: "MOST important to investigate" indicates an adverse reaction. 1) Tagamet decreases gastric secretion by inhibiting the actions of histamine at the H 2 -receptor site; constipation is a common side effect of this medication; should increase fiber in diet; not most important 2) Tagamet should be taken with meals and at bedtime 3) CORRECT— elderly clients and clients with renal problems are most susceptible to CNS side effects (confusion, dizziness) of the medication; dosage may need to be reduced 4) headache may be side effect of medication, or may be caused by need to change glasses; not most important

The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client operates a horse ranch. It is MOST important for the nurse to include which of the following instructions? 1. Ride with a companion and wear an identification bracelet. 2. Carry a cell phone and dressings and tape. 3. Provide significant others with a written itinerary for the day. 4. Temporarily change to activities that are safer for client

Strategy: "MOST important" indicates discrimination is required to answer the question 1) riding with a companion is helpful but does not specifically reduce the risks; should wear an Medic Alert bracelet 2) CORRECT— because of occupation and prescribed anticoagulant, client is at risk for tissue damage; in case of injury, apply pressure to wound and summon help 3) others knowing potential location is relevant but does not reduce risks 4) taking the medication is long-term; nurse should help client integrate appropriate interventions into lifestyle

The nurse cares for clients in the outpatient clinic. A client with a pacemaker calls to report that he just had an episode of dizziness and shortness of breath. Which of the following responses by the nurse is MOST important? 1. "What is your pulse?" 2. "What were you doing before the episode?" 3. "Have you experienced this before?" 4. "Is the area over the pacemaker painful or red?"

Strategy: "MOST important" indicates priority. 1) CORRECT— may indicate pacemaker malfunction; nurse should assess client's current status 2) assess if client was close to electromagnetic field that might interfere with function of pacemaker; more important to assess current status 3) should be asked later in conversation 4) may indicate infection; more important to assess cardiac functioning

The home care nurse visits a client diagnosed with progressive systemic sclerosis. The client complains that she is having more trouble swallowing and moving her right hand. Which of the following responses by the nurse is MOST important? 1. "This must be a difficult time for you." 2. "You should schedule an appointment with your health care provider." 3. "Can you tolerate pressure on your hand?" 4. "Tell me more about the problems you are having swallowing."

Strategy: "MOST important" indicates priority. 1) it is important to allow client to verbalize feelings, but physical needs take priority 2) may be required, but nurse should complete assessment 3) appropriate assessment for Raynaud phenomenon; eating problems take priority 4) CORRECT— progressive systemic sclerosis is a connective tissue disease that causes dysphagia and esophageal reflux because of decreased motility; nurse should assess before determining the appropriate imp

The nurse in the pediatric clinic performs a well-child assessment on a 15-month-old. The child's mother tells the nurse that she is very excited because her mother is visiting. The grandmother rarely visits, and the child's mother is pleased that grandmother and grandchild will spend time together. Which of the following responses by the nurse is MOST important? 1. "Your toddler may be fearful when left alone with her grandmother." 2. "How long is your mother staying?" 3. "Does your mother take any medication?" 4. "I'm sure your mother will enjoy her grandchild."

Strategy: "MOST important" indicates priority. 1) toddlers display less fear of strangers as long as parents are present; when left alone, the toddler may be fearful or anxious; appropriate information for the nurse to relate to the mother; psychosocial need 2) not the most important question 3) CORRECT— because toddlers explore by putting things in their mouths, parents should be aware of all potentially toxic substances in the home; parents should be aware if visitors in the home are taking medication, which should not be left in purses or suitcases lying around 4) safety takes priority

An older man is returned to his hospital room three hours after a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation (CBI). Which of the following observations, if made by the nurse, requires an intervention? 1. The patient is in bed with his legs drawn up to his abdomen. 2. There is 500 cc fluid in the urinary drainage bag. 3. There is 350 cc of reddish urine in the drainage bag. 4. The head of the patient's bed is elevated 45 degrees.

Strategy: "Requires an intervention" indicates a potential complication. 1) CORRECT— indicates pain; also, catheter is taped to thigh, and leg should be kept straight to maintain traction on the catheter 2) expected due to the CBI; assess for shock and hemorrhage; check dressing and drainage; urine may be bright red for 12 h; monitor vital signs 3) expected drainage soon after surgery; CBI contains isotonic fluid used to keep the catheter patent 4) no restriction on positioning as long as leg that has catheter taped to it is straight

The nurse performs teaching for a client receiving alendronate (Fosamax) 10 mg PO OD. The nurse determines that teaching is effective if the client states which of the following? 1. "I will take the medication at lunch." 2. "I'm glad that I don't have to participate in a regular exercise program." 3. "If I forget a dose, I should take it when I remember it." 4. "I should wear sunscreen when I go outside."

Strategy: "Teaching is effective" indicates correct information. 1) take medication first thing in the morning at least half hour before ingesting other medication, food, or drink 2) used for treatment and prevention of osteoporosis; client should participate in regular weight-bearing exercise to increase bone density 3) should only be taken first thing in morning; if dose is missed, skip the dose and resume the next morning 4) CORRECT— causes photosensitivity; wear sunscreen and protective clothing when outdoors

The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient. Thirty minutes later, it is MOST important for the nurse to take which of the following actions? 1. Reposition the patient. 2. Elevate the patient's head and place a pillow under the shoulders. 3. Observe the patient for restlessness and distress. 4. Ambulate the patient.

Strategy: Assess before implementing 1) will promote comfort; other interventions include cool, well-ventilated, quiet room and a back rub 2) will promote comfort 3) CORRECT— nurse should evaluate the actual outcomes; if medication ineffective, will also see inability to concentrate and apprehension 4) more important to allow client to rest

The home care nurse visits an elderly client 1 day following a colonoscopy. The daughter states that her mother has been confused since coming home from the procedure. Which of the following actions should the nurse take FIRST? 1. Instruct the client to increase her intake of fluids. 2. Obtain the client's vital signs. 3. Determine how many times the client has voided. 4. Ask the client if she has experienced abdominal cramping.

Strategy: Assess before implementing. 1) confusion may be sign of hypovolemic shock; client may be dehydrated because of bowel prep, nurse should first assess 2) CORRECT— hypovolemia can occur from bowel prep and altered mental status may be an early indication; assess for decreased blood pressure, increased pulse, light-headedness and dizziness 3) if client dehydrated, will void smaller amounts of concentrated urine; priority is to assess vital signs 4) may experience abdominal cramping caused by insufflation of air

Recently several staff members on the unit have complained of back strain. The nurse determines that the staff is not consistently using correct body mechanics when transferring patients. Which of the following suggestions should the nurse make FIRST? 1. "Encourage your patients to assist as much as possible." 2. "Use your arms and legs when moving a client." 3. "Determine if help is required to transfer a patient." 4. "Position yourself close to the patient."

Strategy: Assess before implementing. 1) decreases the nurse's workload and promotes client strength and independence 2) appropriate action; use the larger muscles of the body and not the back; don't twist spine 3) CORRECT— first step is to assess; determine the weight to be transferred and if help (other staff members, mechanical devices) is required and available 4) minimizes the force felt by the nurse; always keep weight to be lifted close to the body

The nurse is making staff assignments on the medical/surgical unit. The nurse should assign a nursing assistant to care for which of the following clients? 1. A client diagnosed with a CVA 2 weeks ago requiring assistance ambulating. 2. A client diagnosed with COPD who is in acute distress requiring assistance bathing. 3. A client receiving total parenteral nutrition through a PICC line requiring a dressing change. 4. A client diagnosed with type 1 diabetes on mechanical ventilation requiring a bath.

Strategy: Assign the nursing assistant to stable clients with standard, unchanging procedures 1) CORRECT— stable patient requiring a standard, unchanging procedure; instruct nursing assistant about the how far to walk the client and any untoward occurrences to report 2) client requires assessment; not appropriate for the nursing assistant 3) requires skill of the RN 4) requires skill of the RN

The nurse cares for a patient hospitalized for a head injury. The client is receiving 0.9% sodium chloride at 100 cc/h and has an indwelling Foley catheter in place. The nurse notes the patient's urinary output is 1,000 cc in 3 hours. Which of the following actions by the nurse is MOST appropriate? 1. Contact the physician. 2. Decrease the amount of fluids the patient is receiving. 3. Assess the client's mucous membranes. 4. Measure the urine specific gravity.

Strategy: Determine if assessment or implementation is appropriate. 1) complete the assessment before contacting the physician; symptoms of diabetes insipidus include excessive urine output, severe dehydration, excessive thirst, anorexia, weight loss 2) ADH deficiency causes the excretion of large volumes of dilute urine; if deprived of fluids, may cause shock 3) may see signs of dehydration, such as poor skin turgor and dry or cracked mucous membranes 4) CORRECT— low specific gravity (1.001 and 1.005) is characteristic of diabetes insipidus; head injury causes interference with production or release of ADH; record I and O, urine specific gravity, and daily weight; ensure client's intake of fluid and administer DDAVP

The mother of an 8-month-old boy is concerned because her son has started to scream and refuses to eat when left with the child-care provider. Which of the following statements by the nurse is BEST? 1. "Start looking for a different child-care provider." 2. "Check your son for bruises and other injuries." 3. "Remember that this is just a phase your son is going through." 4. "Hand your child his blanket as you say goodbye."

Strategy: Determine outcome of each answer. Is it desired? 1) separation anxiety indicates normal development; fear of strangers begins at 7 months, peaks at 8 months 2) no indication of abuse; normal development 3) is normal growth and development, question asks for best response; phases-protests, cries/screams for parents and is inconsolable by others; despair, cry ends but is less active, not interested in food or play; denial, appears adjusted, appears interested in environment, ignores parents when they return 4) CORRECT— exhibiting separation anxiety; reassure child by offering favorite blanket or toy, talk to infant when leaving the room, and allow infant to hear parent's voice on telephone

The nurse cares for clients on the neurological unit. After receiving report, which of the following clients should the nurse see FIRST? 1. A client who is non-responsive with intermittent limb movement. 2. A client whose muscle tone of all four limbs is flaccid. 3. The client who is non-responsive but follows the staff with his eyes. 4. The client who immediately withdrawals from painful stimuli.

Strategy: Determine the most unstable client. 1) limb movement indicates brain injury is not severe 2) CORRECT— flaccidity most indicative of serious irreversible impairment 3) tracking with the eyes indicates client less impaired than client with flaccid muscles 4) indicates a higher level of consciousness, according to Glasgow Coma Scale

A tornado roared through a populated area, causing multiple casualties. Which of the following patients should the nurse see FIRST? 1. A patient with a small penetrating abdominal wound caused by flying debris. 2. A patient with blunt trauma to the abdomen that caused bruising. 3. A patient complaining of chest pain with asymmetrical chest movement noted. 4. A patient who is confused and restless with no visible injuries.

Strategy: Determine the most unstable patient. 1) may cause bleeding; injury does not appear to be life-threatening 2) second patient that should be seen; observe for ecchymosis, which indicates retroperitoneal bleeding into the abdominal wall 3) CORRECT— indicates flail; monitor for shock, give humidified oxygen, manage pain, monitor ABGs 4) appears most stable

The nurse supervises the transfer of an elderly client with left-sided weakness from the bed to the chair. After assisting the client to a sitting position, which of the following actions should the nurse take NEXT? 1. Place nonskid shoes on the client's feet. 2. Instruct the client that she will be moving toward her left side. 3. Ask the client to pivot on her right foot. 4. Support the left leg with the nurse's knee.

Strategy: Determine the outcome of each answer. 1) CORRECT— instruct client to wear shoes when transferring, nonskid soles decrease the chance of falls 2) if client has weaker side, transfer toward the stronger side; nurse should assess if a transfer belt is required; place chair at 45° angle to the bed 3) appropriate action; first put shoes on client; instruct client to use armrests on chair for support 4) appropriate action to provide stability to weak leg so that client can stand during transfer

The nurse cares for an older woman with frequent bladder incontinence following a cerebrovascular accident (CVA). Which of the following actions by the nurse is MOST appropriate? 1. Perform intermittent catheterizations using sterile technique 2. Teach the patient how to perform Valsalva maneuver. 3. Instruct the patient how to perform the Cred é maneuver. 4. Toilet the patient when she awakens in the morning and before and after meals.

Strategy: Determine the outcome of each answer. 1) only used for problems with retention 2) straining and bearing down on the abdominal muscles alters the heart rate; will not prevent incontinence 3) used to initiate urination when there is retention; place a cupped hand over the bladder and push inward and downward 4) CORRECT— will establish a regular toileting routine

A client is receiving packed red blood cells. Several minutes after the infusion is started, the client complains of nausea and low back pain. It is MOST important for the nurse to take which of the following actions? 1. Obtain a urine specimen. 2. Start an IV of D 5 W. 3. Discard the blood container in a biohazard container. 4. Decrease the rate of the transfusion.

Strategy: Determine the outcome of each answer. Is it desired? 1) CORRECT— should be sent to lab for hemoglobin determination; symptoms of hemolytic reaction include nausea, vomiting, pain in lower back, hypotension, increase in pulse rate, decrease in urinary output, hematuria 2) should restart normal saline; stop the blood, supportive care: oxygen, Benadryl, airway management 3) container should be returned to lab 4) should be discontinued due to hemolytic reaction; draw blood sample for plasma, hemoglobin culture, and retyping

A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the patient becomes verbally abusive. Which of the following actions by the nurse is MOST appropriate? 1. Tell the patient to lower his voice. 2. Ask the patient what he wants from the cafeteria. 3. Calmly but firmly escort the patient to his room. 4. Assign a nursing attendant to accompany the patient to the cafeteria.

Strategy: Determine the outcome of each answer. Is it desired? 1) do not argue; carry out limit-setting 2) reinforces inappropriate behavior 3) CORRECT— limit-setting, ensures safety; patient with substance abuse needs consistent, undivided staff approach, clearly defined expectations, as well as limit-setting; avoid threats and promises 4) reinforces abusive behavior

The nurse cares for a patient with chest tubes. Two days after insertion, the chest tube is accidentally pulled out of the pleural space. Which of the following actions should the nurse take FIRST? 1. Don sterile gloves and replace the tube. 2. Apply pressure with a dressing that is tented on one side. 3. Instruct the client to cough and deep-breathe. 4. Auscultate the lung.

Strategy: Determine the outcome of each answer. Is it desired? 1) inserting the tube is a medical procedure 2) CORRECT— decreases chance that atmospheric air will enter pleural space and allows for escape of pleural air 3) increases the amount of atmospheric air that enters the pleural space 4) priority is covering the opening; listen to lungs after emergency measure instituted

The nurse counsels a client diagnosed with degenerative joint disease. It is MOST important for the nurse to include which of the following instructions? 1. "Place your joints in the position of comfort." 2. "Place your joints in a flexed position." 3. "Place your joints in full extension." 4. "Place your joints in their functional position."

Strategy: Determine the outcome of each answer. Is it desired? 1) may lead to limitations in movement; place in functional position 2) would cause flexion contractures that limit mobility; only use a small pillow under the head or neck; do not use large pillows under the knees; to reduce back discomfort, elevate legs 8-10 inches 3) should be placed in correct functional position to maintain mobility of joint 4) CORRECT— maintains mobility of joints

A client is admitted to the labor and unit in a sickle-cell crisis. Which of the following nursing actions should the nurse take FIRST? 1. Administer oxygen. 2. Turn client to right side. 3. Begin an IV with normal saline. 4. Administer antibiotics.

Strategy: Determine the outcome of each answer. Is it desired? 1) second action; crisis caused by extensive extracellular sickling 2) no reason to turn to right side; do not keep knees and hips in a flexed position 3) CORRECT— dehydration perpetuates cell sickling; intake should be at least 200 cc/hour 4) more susceptible to blood-borne pathogens; frequent handwashing; avoid people with URI

The nurse on the medical/surgical floor receives four new admissions. Which of the following clients should be placed in a private room? 1. A client with a draining abdominal abscess covered with a dressing. 2. A client diagnosed with influenza. 3. A client diagnosed with cancer who appears septic. 4. A client with diverticulitis complaining of abdominal pain.

Strategy: Determine the outcome of each answer. Is it desired? 1) standard precautions required as long as the abscess is covered with a dressing and the dressing contains the drainage 2) CORRECT— requires droplet precautions; place in private room or with patients with the same infection; maintain spatial separation of at least 3 feet; door can remain open 3) microorganisms have entered the bloodstream due to impaired immune function; standard precautions; assess for s/s shock 4) standard precautions

The nurse performs dietary teaching with a client who has hepatitis B. Which of the following menus, if selected by the client, is BEST? 1. Hamburger, french fries, a dill pickle, and malted milk. 2. Lean roast beef, baked potato, green beans, and coffee. 3. Bacon, eggs, toast with butter, and milk. 4. Biscuits with sausage, gravy, and buttered grits, and orange juice.

Strategy: Evaluate the nutrients in each menu. 1) high-fat foods; encourage fruits, vegetables, cereals, lean meat 2) CORRECT— high-carbohydrate, low-fat 3) high-fat foods; not allowed: marbled meats, avocados, milk, bacon, egg yolks, and butter 4) high-fat foods

The nurse performs a prenatal assessment on a client at 20 weeks' gestation. Identify the location where the nurse expects to palpate the client's fundus.

Strategy: Recall the fundal height at 20 weeks. The correct answer: at the level of the umbilicus. 10 to 12 weeks — fundus slightly above symphysis pubis 16 weeks — fundus halfway between symphysis pubis and umbilicus 20 to 22 weeks — fundus at the level of the umbilicus 28 weeks — fundus three fingerbreadths above the umbilicus 36 weeks — fundus just below ensiform cartilage

The nurse on the medical unit is called to the room of an elderly client. The nurse finds the client sitting up in bed complaining of pressure in his chest and pain in his jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a history of hypertension and is receiving IV antibiotics for a diagnosis of pneumonia. Which of the following actions should the nurse take FIRST? 1. Administer oxygen at 4 L/min via nasal canula. 2. Place the client on a cardiac monitor and obtain a 12-lead ECG. 3. Obtain blood for CK-MB, troponin, and myoglobin levels. 4. Assess patency of the client's IV line.

Strategy: Remember the ABCs. 1) CORRECT— implementation; ABCs take priority; exhibiting signs of acute coronary syndrome (ACS) which may be unstable angina, myocardial ischemia or infarction 2) assessment; should be completed after oxygen administration; provides data for physician to determine required treatment 3) assessment; third action, elevations are indicative of MI; do not wait for lab results before beginning treatment 4) assessment; ensure route for IV medication such as nitroglycerin, morphine, fibrinolytic, and heparin

The nurse cares for a laboring patient. The patient requests something for pain and says to the nurse, "I'm really scared of shots." Which of the following responses by the nurse is BEST? 1. "A shot is your only option, because labor slows the GI tract." 2. "I can give you a pill now, but it will not last as long as an injection." 3. "What was your previous experience with shots?" 4. "What are you afraid of?"

Strategy: Remember therapeutic communication. 1) is an accurate response but does not allow the client to express her feelings 2) oral medication is not recommended in labor because of the decrease in GI motility 3) CORRECT— an assessment to assist the nurse in gathering information toward achieving pain relief and to this particular client's psychological state; assess before intervening 4) judgmental and nontherapeutic

The nurse determines that which of the following clients is MOST at risk to develop gastroesophageal reflux disease (GERD)? 1. A 16-year-old African American male who had an NG tube for 3 days after surgery for a ruptured appendix. 2. A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-tube in place. 3. A 52-year-old Caucasian female who is 5'5" tall and weighs 185 pounds. 4. A 65-year-old Caucasian male with a laryngectomy for laryngeal cancer.

Strategy: Think about each answer. 1) NG tube is a risk factor; NG tube compromises esophageal sphincter function and permits acidic stomach contents to enter the esophagus 2) being female is a risk factor for GERD 3) CORRECT— GERD is gastrointestinal contents flowing backward into the esophagus; risk factors include female, over the age of 45, and obesity; GERD appears more often in Caucasians 4) risk factors include age and ethnicity; smoking is also a risk factor for GERD

The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a prenatal visit on June 6. Her last menstrual period was December 10. The nurse expects the client's fundal height to measure 1. 24 cm. 2. 26 cm. 3. 28 cm. 4. 30 cm.

Strategy: Think about each answer. 1) incorrect, determine EDC based on N ä gele's rule-date LMP Dec. 10; EDB-Sept. 17; client is 26 weeks pregnant; from 24-34 weeks, fundal height correlates well with weeks of gestation; 24 cm is approximately 24 weeks' gestation 2) CORRECT— client is 26 weeks pregnant; fundal height should correlate with weeks of pregnancy 3) fundus is too high 4) fundus is too high

The nurse assesses a client diagnosed with paranoid schizophrenia. Which of the following assessments indicates to the nurse that the client may need assistance with self-care activities? 1. The client speaks in a low monotone voice. 2. The client had suicidal ideation on two previous admissions. 3. The client is fearful that poison is being placed in his food. 4. The client is unable to maintain eye contact with the nurse.

Strategy: Think about each answer. 1) may appear guarded, intense, and reserved; may adopt a superior, hostile, and sarcastic attitude; will have no bearing on self-care activities 2) may indicate depression 3) CORRECT— paranoia is an irrational suspicion; cannot be changed by experience or reality; may prevent client from eating; provide food in closed containers to prevent the suspicion of tampering 4) indicates a negative symptom of schizophrenia and contributes to poor social functioning but does not help client needs with self-care activities

The nurse cares for client diagnosed in stage I chronic renal failure. During the nursing assessment, the nurse expects the client to state which of the following? 1. "I don't seem to urinate as much as I used to." 2. "I seem to have more swelling in my feet and ankles." 3. "I urinate more at night." 4. "The doctor told me I need dialysis."

Strategy: Think about what the client's words mean. 1) oliguria occurs during stage II (renal insufficiency) 2) occurs during stage II 3) CORRECT— stage I is diminished renal reserve; renal function is reduced but healthier kidney is able to compensate; since kidney not as able to concentrate urine, client has polyuria and nocturia 4) required in stage III (end-stage renal disease)

The nurse prepares a client for a skin biopsy. Which of the following statements, if made by the client, should the nurse report to the physician? 1. "I have been taking aspirin for my aching joints." 2. "I applied lotion to my skin after my shower last night." 3. "I laid out in the sun yesterday." 4. "I had coffee and a sweet roll for breakfast this morning."

Strategy: Think about what the words mean. 1) CORRECT— aspirin can increase the risk for bleeding and should be reported 2) does not affect the biopsy 3) not a good health habit, but it does not affect the biopsy 4) a punch or shave biopsy is usually performed on the skin and does not require NPO; clean biopsy site once a day with tap water or saline; leave site open