NCLEX-PN Review

The nurse is suctioning an endotracheal tube (ET) for an intensive care unit client who is being mechanically ventilated. Five minutes after suctioning, which primary outcomes should tell the nurse that the suctioning has been successful? Select all that apply.

*Clear lung sounds *Increase in O2 saturation *Heart rate on monitor within normal limits Rationale: The most positive outcome related to endotracheal suctioning is hearing clear lung sounds when the lungs are auscultated. Also, an increase in O2 saturation and a normal heart rate on the monitor would be a successful suctioning outcome.

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

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

The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching?

"I can resume sexual activity at any time." Rationale: It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Lochia is bright red for about 3 days postpartum and then changes to brownish pink discharge (from days 4 to 10), then white (from days 11 to 14). Walking is an excellent form of exercise in the immediate postpartum period because it is not strenuous and maintains circulation. An adequate intake of fluid (2000 mL daily) is important to prevent dehydration and constipation.

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?" Rationale: When delusional, a person truly believes what he or she thinks to be real is real. The person's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

"I need to take my child's rectal temperature daily." Rationale: The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

A client with Parkinson's disease is beginning treatment with carbidopa-levodopa (Sinemet). Which statement made by the client indicates the need for further teaching?

"I should take my medication after a full meal." Rationale: Carbidopa-levodopa should be taken on an empty stomach with a full glass of water to enhance absorption. Because the medication can cause orthostatic hypotension, clients should be taught to change positions slowly. To ease the side effect of dry mouth, sugarless chewing gum, hard candy, and frequent mouth rinses are indicated. The side effect of sleep difficulty should be reported. In addition, the client is taught to avoid high-protein meals because it affects the effectiveness of the medication.

The nurse is instructing a client with Addison's disease about a newly prescribed medication, fludrocortisone acetate (Florinef). Which statement by the client indicates a need for further teaching?

"I will be glad to gain weight." Rationale: The client should notify the health care provider of weight gain. The client should take oral drugs with food or milk. The client should wear a Medic-Alert bracelet. Fludrocortisone acetate (Florinef) should not be stopped abruptly but should be tapered down.

A client with breast cancer has been given a prescription for cyclophosphamide. The nurse determines that the client understands the proper use of the medication if the client makes which statement?

"I will increase fluid intake to 2 to 3 L/day." Rationale: A toxic effect of cyclophosphamide is hemorrhagic cystitis. The client should drink large amounts of fluid during the administration of this medication. Clients also should observe for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be encouraged to increase potassium intake. The client would not be instructed to alter magnesium intake.

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

"Let me know if you change your mind, and I'll get you something to eat." Rationale: Delusions are false fixed beliefs, and it is never useful to argue with the client regarding the content of the delusion. This can intensify the client's retention of the irrational beliefs. Once a client describes a delusion, it is important not to dwell on it. Rather, focus the conversation on more reality-based topics. Option 2 reinforces caring. Option 1 is rigid and is directly challenging to this client's delusion. Option 3 is using the nontherapeutic technique of interpreting and may be interpreted as challenging to the client. Option 4 is plausible, but the expectation to "participate in all activities" is not realistic.

A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. Which response by the nurse is appropriate?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic at some point before the age of 3 years." Rationale: Most children who are infected with HIV develop symptoms within the first 9 months of life. The remainder of these infected children become symptomatic sometime before the age of 3 years. Children, with their immature immune systems, have a much shorter incubation period than adults. Options 1, 2, and 3 are incorrect responses.

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response should the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today." Rationale: Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery. Appropriate antenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up repeat urine cultures. Option 4 is the only therapeutic response and is the response that identifies accurate information.

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply.

*50 mL of drainage in the drainage-collection chamber *The drainage system is maintained below the client's chest. *An occlusive dressing is in place over the chest-tube insertion site. *Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and requires registered nurse and health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse is reinforcing medication discharge instructions for a client who has just begun taking isocarboxazid (Marplan) for depression and knows that the client needs further teaching after stating that which foods are safe to eat? Select all that apply.

*Avocado *Bologna Rationale: Foods that are restricted for clients who take monoamine oxidase inhibitors (MAOIs) are foods that contain tyramine and include avocados; figs; fermented, smoked, and organ meats; dried and cured fish and most cheeses; foods with yeast; imported beers and Chianti wines; and some soups that contain protein extract. Apples, tomatoes, and broccoli do not contain tyramine and are safe to eat.

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

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

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

*Rest during the acute phase. *Wear a supportive, nonunderwire bra. *Maintain a fluid intake of at least 3000 mL. *Continue to breastfeed if the breasts are not too sore. Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. Continued decompression of the breast by breastfeeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

*Wearing gloves when emptying the client's bedpan *Keeping all linens in the room until the implant is removed *Wearing a film (dosimeter) badge when in the client's room *Wearing a lead apron when providing direct care to the client

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply.

1. Place the child on a low-bacteria diet. 2. Change dressings using sterile technique. 3. Perform meticulous hand washing before caring for the child. Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

A client received a dose of regular insulin (Humulin R) this morning at 7:00 am. At which time should the nurse likely anticipate the potential for a hypoglycemic reaction to occur?

10:00 am Rationale: Humulin R is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. During the peak action of insulin is when hypoglycemic reactions are most likely to occur. This makes option 2 correct.

The nurse determines that an adult male client admitted with dehydration and a hematocrit level of 56% has received adequate fluid volume replacement if which repeat hematocrit level is noted?

48% Rationale: The normal hematocrit level for an adult male is 42% to 52%. Thus, 48% is the only correct choice. The client who is dehydrated has an elevated level as a result of hemoconcentration. The client's level may be expected to drift back down to within the normal range after the fluid volume has been adequately restored. The remaining options are too high and indicate fluid replacement is still indicated.

The nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder?

A child of Mediterranean descent Rationale: Beta-thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations. Options 1, 3, and 4 are not risk factors for this disorder.

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery Rationale: The LPN should care for the most stable, least high-risk client. In this case, a client who had a scheduled cesarean delivery would be the most stable client. A client who is receiving a blood transfusion will need ongoing assessment and is at higher risk than a client recovering from a scheduled cesarean delivery. Von Willebrand disease is a type of hemophilia that puts the client at high risk for hemorrhage. A client with a previous postpartum hemorrhage is also at higher risk for postpartum complications.

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which? Agoraphobia

Agoraphobia Rationale: Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health.

A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the health care provider to prescribe?

Amniocentesis for fetal surfactant level Rationale: An amniocentesis is performed to obtain a specimen of fluid to detect the surfactant level. By 20 weeks of gestation the lungs have matured functionally enough for the fetus to survive outside the uterus (age of viability), but special care in the neonatal intensive care unit (NICU) would be required. A biophysical profile consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and the volume of amniotic fluid (AFI). Chorionic villus sampling consists of obtaining a small part of the developing placenta to analyze fetal cells at 10 to 12 weeks of gestation. The ultrasound scan measures the amniotic fluid pockets in all four quadrants surrounding the mother's umbilicus and produces an amniotic fluid index (AFI). From 5 to 19 cm is considered normal.

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which would be the initial action by the nurse who observed the error?

Ask the nurse if he or she intends to report the error. Rationale: The initial action by the nurse who observed the error would be to ask the nurse if he or she intends to report the error. To ensure client safety, all errors need to be reported. The client also needs to be assessed immediately. An incident report needs to be completed by the nurse who administered the incorrect medication. The appropriate documentation also needs to be made in the client's record by the nurse who administered the incorrect medication. If the nurse who made the error indicates that the error will not be reported, then it may be necessary to contact the supervisor.

The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure.

Atrial fibrillation Diagram of normal sinus rhythm as seen on ECG. In atrial fibrillation the P waves, which represent depolarization of the top of the heart, are absent

Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are β-blockers.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva. Rationale: Roseola is transmitted via saliva; therefore, others should not share drinking glasses or eating utensils. Options 1, 2, and 4 are not accurate instructions regarding the prevention of the transmission of roseola.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can occur secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

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

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

The nurse is caring for a client with Paget's disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse checks to see that which medication is available in the stock medication supply area for possible use to reverse this elevation?

Calcitonin (Calcimar) Rationale: The normal serum calcium level is 4.5 to 5.5 mEq/L or 9 to 11 mg/dL. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D should be avoided. Calcium gluconate and calcium chloride would be used to treat tetany that results from acute hypocalcemia.

The nurse is assisting in caring for a postterm neonate immediately after admission to the nursery. The priority nursing action should be to monitor which?

Blood glucose levels Rationale: The most common metabolic complication in the postterm newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the postterm neonate may exhibit polycythemia; however, this also does not require immediate attention.

Latanoprost (Xalatan) drops are prescribed for the client with glaucoma. The client returns to the health care clinic for evaluation. Which finding noted in the client indicates a side effect associated with the use of these eye drops?

Brown pigmentation of the iris Rationale: Latanoprost is a topical medication used to lower intraocular pressure in clients with open-angle glaucoma and ocular hypertension. The most significant side effect is heightened brown pigmentation of the iris. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. The heightened pigmentation stops progressing when the medication is discontinued but does not regress. Options 1, 2, and 3 are inaccurate and not associated side effects of the medication.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts Rationale: The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

A client has been started on long-term therapy with rifampin (Rifadin). Which information about this medication should the nurse provide to the client?

Causes orange discoloration of sweat, tears, urine, and feces Rationale: Rifampin (Rifadin) should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a health care provider. The medication should be administered on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes orange-red discoloration of body secretions and will permanently stain soft contact lenses.

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

Checking the wound site for drainage from the drain Rationale: The wound site needs to be checked for drainage from the drain; the drainage can excoriate the skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red. Aseptic technique must be used when changing the dressing to avoid contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The tube is not advanced.

The nurse is assigned to care for a newly admitted client and is reviewing the health care provider's prescriptions. The nurse notes that the health care provider has prescribed a medication dose that is twice the amount that the client reports taking before admission. Which nursing action is appropriate?

Consult with the registered nurse (RN). Rationale: If the nurse determines that a health care provider's prescription is unclear or if the nurse has a question about a prescription, the nurse should consult with the RN, who will then contact the health care provider before implementing the prescription. Under no circumstances should the nurse carry out the prescription unless the prescription is clarified. Questioning the client regarding the accuracy of the dosage of the medication may seem like a viable option, but this action also may cause the client to become upset. The nurse would not administer the medication, nor would the nurse administer an altered dosage.

A pregnant client is seen in the health care clinic with reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion?

Consume dry crackers before getting out of bed. Rationale: Some strategies for decreasing morning sickness are keeping crackers, melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats; and consuming adequate fluid between meals.

A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?

Decreased wheezing Rationale:Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute.

The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider?

Each rescue breath should be given over 1 second and should produce a visible chest rise. Rationale: During adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. Health care providers should employ a 30 compressions-to-2 ventilations ratio for the adult victim. Options 1, 2, and 3 are incorrect.

The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be inserted into the skeletal muscles. Rationale: An electromyogram involves insertion of needle electrodes into selected skeletal muscles to evaluate changes and electrical potential of the muscles and the nerves that lead to them. The test is useful in evaluating suspected lumbar or cervical disk disease, myasthenia gravis, muscular dystrophy, and other musculoskeletal diseases. The client should be reassured that the needle will not electrocute him or her, and that he or she will experience sensations comparable to an injection as the needles are inserted. An informed consent is required, and no other special preparation is required for this test.

The nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a nursing student to identify the structure in which fertilization of an ovum takes place. The student answers correctly by identifying which location?

Fallopian tube Rationale: Fallopian tubes, also called oviducts, are 8 to 14 cm long and quite narrow. The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube.

The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The client states that she was just going to ring the call bell for the nurse. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy?

Fluid (circulatory) overload Rationale: With fluid (circulatory) overload, the client has the presence of crackles in the lungs in addition to dyspnea. Hypovolemic shock (restlessness, increased pulse, decreased blood pressure) is not likely to occur in a client receiving fluids. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.

A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed?

High-fiber diet Rationale: A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation. A high-iron diet is for clients with anemia to help make hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium diet to prevent increased fluid volume.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping Rationale: The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

The nurse is reinforcing medication instructions to a client who has been prescribed simvastatin (Zocor). Which is the action of simvastatin?

It inhibits hepatic synthesis of cholesterol. Rationale: The process of cholesterol reduction begins with inhibition of hepatic HMG-CoA reductase, the rate-limiting enzyme in cholesterol biosynthesis. In response to decreased cholesterol production, hepatocytes synthesize more HMG-CoA reductase. As a result, cholesterol synthesis is restored. However, for reasons that are not fully understood, inhibition of cholesterol synthesis causes hepatocytes to synthesize more low-density lipoproteins (LDL) receptors. Therefore, options 2, 3, and 4 are incorrect.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease?

It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.

The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention?

Laryngeal stridor Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

The nurse should include which information when reinforcing home care instructions for a client who has peptic ulcer disease?

Learn to use stress reduction techniques. Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client also should avoid intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances.

A client with multiple sclerosis is receiving dantrolene (Dantrium) for relief of muscle spasticity. The nurse checks the results of which laboratory value periodically prescribed while the client is taking this medication?

Liver function studies Rationale: Dantrolene can cause liver damage, and the nurse should monitor the results of liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The other options are incorrect.

The nurse is assisting in caring for a client with a diagnosis of bladder cancer who recently received chemotherapy. The nurse receives a telephone call from the laboratory who reports that the client's platelet count is 20,000/mm3. Based on this laboratory value, the nurse revises the plan of care and suggests including which intervention?

Monitor skin for the presence of petechiae. Rationale: When the platelet count is decreased, the client is at risk for bleeding. A high risk of hemorrhage exists when the platelet count is less than 20,000/mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000/mm3. The client should be assessed for signs of bleeding. Options 1, 2, and 3 are specific interventions related to the risk of infection and although they may be a component of the plan of care, they are not specific to the risk for bleeding. Contact with fresh flowers is avoided when the client is at risk for infection and not necessarily when the client is at risk for bleeding. In addition, option 1 is not a therapeutically stated instruction to the client.

A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action?

Notify the registered nurse of the findings. Rationale: The client is showing signs of fluid retention and possible excess fluid intake. Crackles, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The problem may or may not be related to the parenteral nutrition. Other possible causes of fluid retention include impaired respiratory and cardiovascular function, impaired kidney function, or a combination of factors. The nurse needs to notify the registered nurse of the findings. The registered nurse will then notify the health care provider for further prescriptions. Option 2 will have little, if any, effect on peripheral edema and weight gain. Option 3 infers that a diuretic will help the situation, and it is possible that the health care provider will prescribe a diuretic; however, the health care provider needs to be aware of the change in the physical condition of the client. The nurse should not increase or decrease the rate of parenteral nutrition infusions without a health care provider's prescription to do so.

The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action?

Notify the registered nurse. Rationale: Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse, who will notify the health care provider immediately. The other options are incorrect nursing actions. Ice is not applied to the surgical site unless prescribed. The client is not positioned on the operative side because of the risk of increasing intraocular edema from swelling. Although pain medication and an antiemetic may be prescribed, the client's symptoms indicate a serious complication requiring health care provider notification.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons but should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention.

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record?

Painless, progressive loss of vision Rationale: A cataract is any opacity of the crystalline lens of the eye. The classic symptom of cataracts is painless progressive loss of vision in one or both eyes. Some individuals also complain of glare from bright lights. Occasionally pain can result when the lens becomes swollen and blocks the normal flow of aqueous fluid, causing increased intraocular pressure. Color blindness is not an associated symptom.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed. Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse should identify potential areas of harm to the client.

The mother of a child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which should require further investigation?

Possible sexual abuse Rationale: A diagnosis of chlamydial conjunctivitis in a non-sexually active child should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis but not chlamydial conjunctivitis.

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

Vital signs Rationale: A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

A male child who had surgery to correct hypospadias is seen in a health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias?

Renal anomalies Rationale: The nurse should ask the child's parents about the child's kidney function because hypospadias may be associated with renal anomalies. The incorrect options are not associated with a long-term effect of hypospadias.

The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse's immediate response?

Replace the tracheostomy tube. Rationale: If decannulation of a tracheostomy tube occurs 72 hours after surgical placement of the tracheostomy, the nurse prepares to replace the tube. The nurse also calls for help immediately. The nurse extends the client's neck and opens the tissues of the stoma to secure an airway. With the obturator inserted into the new tracheostomy tube, the nurse quickly and gently replaces the tube and immediately removes the obturator. The nurse checks for airflow through the tube and for bilateral breath sounds. If unable to secure the airway, the nurse notifies the respiratory therapist and attempts to ventilate the client with a bag-valve mask (resuscitation bag) while waiting for help. If the client is in distress and further attempts to secure the airway fail, the nurse calls the resuscitation team, including an anesthesiologist, for assistance and calls a code if necessary.

The nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse makes certain that what equipment is available, in the event that the drainage system needs to be changed?

Rubber-shod clamps Rationale: If the drainage system needs to be changed, the registered nurse will use rubber-shod clamps to clamp the tube near the client's chest while the drainage system is changed. This procedure is done quickly and with the assistance of another nurse. The clamps are removed immediately after reconnection of the new drainage system. Agency procedure regarding clamping chest tubes is always followed, and a health care provider's prescription for clamping the tube may be required. If clamps must be used, the best time to apply them is after expiration. An occlusive dressing such as a petrolatum (Vaseline) gauze dressing is used when a chest tube is removed. Options 2 and 4 are not needed for changing a drainage system.

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which?

Sit beside the client in silence and verbalize occasional open-ended questions. Rationale: Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option 4 relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 is the best action because it provides for client supervision and communication as appropriate.

A client has undergone subtotal gastrectomy and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management?

Smaller, more frequent meals should be eaten. Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation.

The nurse is reinforcing dietary instructions to a client who is currently prescribed probenecid (Benemid). Which food should the nurse encourage the client to continue to eat?

Spinach Rationale: Probenecid inhibits the reabsorption of uric acid by the kidneys and promotes excretion of uric acid in the urine. Clients taking this medication are instructed to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. Spinach is not a high-purine food.

The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?

Sulfisoxazole Rationale: A neurogenic bladder prevents the bladder from completely emptying because of the decrease in muscle tone. The most likely medication to be prescribed to prevent urinary tract infection would be an antibiotic. A common prescribed medication is sulfisoxazole. Prednisone relieves allergic reactions and inflammation rather than preventing infection. Furosemide promotes diuresis and decreases edema caused by heart failure. IVIG assists with antibody production in immunocompromised clients.

When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is essential?

Test the drainage for glucose. Rationale: After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet. Rationale: Vision that is 20/20 is normal; that is, the client can read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

The nurse reads a client's tuberculin skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that which statement is true for this client?

The client has been exposed to tuberculosis. Rationale: A client who tests positive on a tuberculin skin test has either been exposed to tuberculosis or has inactive (dormant) tuberculosis. The client must then be tested by chest x-ray and sputum culture to confirm the diagnosis.

A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop for which reason?

The client is unconsciously attempting to control unpleasant thoughts or feelings. Rationale: Repetitive acts are characteristic of clients who have obsessive-compulsive disorder. The rituals performed are an unconscious response; these rituals help divert and control the client's unpleasant thoughts or feelings in order to prevent acting on those feelings. The interpretations in the other options are incorrect.

The nursing student is asked about the medication latanoprost (Xalatan) and how this medication helps glaucoma. The student responds correctly by identifying that which is the medication's mechanism of action?

To facilitate the outflow of aqueous humor Rationale: Latanoprost, an analogue of prostaglandin F2 alpha, is used to treat glaucoma and is applied topically to lower intraocular pressure (IOP) in clients with open-angle glaucoma and ocular hypertension. Latanoprost lowers IOP by facilitating aqueous humor outflow, in part by relaxing the ciliary muscle. Sympathomimetics and beta-blocker eye medications reduce the production of aqueous humor.

The nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse explains to the parents that this medication is used for which purpose?

To protect the newborn from contracting an eye infection from the birth process Rationale: The use of eye prophylaxis with an agent such as erythromycin protects the newborn from contracting a conjunctival infection during birth. This infection, called ophthalmia neonatorum, results from maternal vaginal infection with chlamydia or gonorrhea. This prophylaxis is mandatory in the United States.

The nurse receives a call from the mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse should give which response?

Touch the object gently with a cotton swab, and lift it out. Rationale: The most effective method that would cause the least amount of trauma would be to lift the foreign body from the eye. It should not be allowed to remain and "work its way out." Irrigating the eye may cause the foreign body to move and cause trauma in another area of the eye.

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which problem is most likely to occur during this stage?

Urinary retention caused by the loss of sensation to void and rapid bladder filling Rationale: The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax. Options 1 and 2 relate to the first stage of labor. Option 3 relates to the second stage of labor. Option 4 is related to the third and fourth stages of labor.

The nurse working in a pediatric clinic is preparing to administer childhood vaccinations to a 15-month-old child. Which vaccine should be added to the child's routine immunizations at this time because the child is older than 12 months of age?

Varicella Rationale: Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i.e., children who lack a reliable history of chickenpox and have not been vaccinated). The other vaccines are administered on or before age 1 year.

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which?

Vit B12 Rationale: Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of monthly injections of vitamin B12. Thiamine is most often prescribed for the client with alcoholism. Iron is administered for iron deficiency anemia, and folic acid is prescribed for folic acid deficiency.

The nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where?

Vulva Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion most commonly is noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be associated directly with venous congestion.