NCLEX Practice 1

Detention center staff asked for a mental health evaluation of a 21-year-old woman after the client stabbed themself with a fork and woke from nightmares in fits of rage. The evaluation revealed that the client was kidnapped and held from ages 8 to 16 by a convicted child pornographer. The client said they never contacted their family after being released from captivity. In what order of priority from first to last should the nurse implement the steps? All options must be used.

Initiate suicide precautions. Offer empathy and support, and be nonjudgmental and honest with the client. Encourage safe verbalizations of the client's emotions, especially anger. Ask the client if they wish to contact the their family while hospitalized. Safety is a priority after the client stabbed herself. A survivor of trauma/torture needs empathy, support, honestly, and a nonjudgmental stance from the nurse. Then the client is more willing to learn safe ways to express feeling, especially anger. It will be the client's decision if the client wants to contact their family and, if so, under what conditions. The client would need extensive preparation before any contact with family.

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client?

Keep the legs elevated when sitting or lying down. The nurse instructs the client to elevate the legs to improve venous return and alleviate discomfort. Walking is encouraged to increase venous return. Sclerotherapy or laser treatment is done for cosmetic reasons, but it does not improve circulation. Surgery may be performed for severe venous insufficiency or recurrent thrombophlebitis in the varicosities. Femoral-popliteal bypass graft is a surgical intervention for arterial disease.

A client with diabetes is asking the nurse about drinking alcohol. The nurse's best response would be:

"Alcohol may decrease the normal physiologic reactions in the body that produce glucose. Therefore, there is a risk for hypoglycemia." This is the systemic physiologic response to alcohol in the body of a diabetic client. Suggesting an alternative source of beverage does not address the client's question. Suggesting more frequent monitoring is incorrect based on the body's delayed reaction to the glucose. Telling the client to set an alarm clock is not best nursing practice.

When giving a change-of-shift report, which statement by the nurse should be included? Select all that apply.

"Client A is a 38-year-old female client of Dr. Born with cholecystitis and cholelithiasis." "Client B's pain is best relieved in the left lateral Sims' position." "Client D was able to walk around the unit twice today with no dizziness." "Client F has had 100 mL drainage from the nasogastric tube." When giving a change-of-shift report, the nurse should provide relevant and concise information about the client's diagnosis, health care provider's name, change in status, pain relief strategies, intake/output and level of activity. Calling a client "contrary" is critical in nature and judgmental on the nurse's part. Indicating that the client had visitors all day does not provide sufficient information for ongoing care planning.

A client with an anxiety disorder is admitted to the psychiatric unit because of panic attacks. What statement by the nurse is the most appropriate?

"I am going to ask you some questions to help me understand the anxiety you are experiencing." Nursing assessment questions for clients with anxiety disorders and panic attacks need to be direct and straightforward. Clients with anxiety disorders with panic attacks are fearful about the future and may be reluctant to initiate talking about their anxiety. Knowing the questioning will be coming in an uncertain amount of time will trigger more anxiety. In high anxiety, the brain is not functioning properly and the person is not able to think or process information clearly.

A client diagnosed with colon cancer has a colostomy. The nurse has completed discharge teaching. Which statement would indicate that the client is in need of further teaching?

"I will have to adapt my daily routine around my colostomy changing schedule." The client with the colostomy can lead a normal life. The colostomy can be changed by the client without assistance. Sex, exercise, and swimming are all possible with the colostomy. The daily routine does not need to be altered just because the client has a colostomy.

A client with physical deficits related to a recent cerebral vascular accident states tearfully, "I no longer can take care of myself." Which statement by the nurse is most therapeutic?

"It is hard not to be able to care for yourself." Therapeutic communication is client centered, meaning that it is focused on supporting the client's physical and emotional well-being. The client is in control of the topic and supported in expressing feelings of concern. Responding with open-ended questions or validating statements allows the client an opportunity to explore the ideas and feelings they wish to discuss. The nurse would not offer the condescending or potentially untrue statement that the client will be back to normal. It is also not appropriate to deflect the client's feelings by changing the topic to breakfast or focusing on "positive things."

The nurse is leading group therapy composed of clients with chronic schizophrenia. Which statement by the nurse would most likely lead to decreased mistrust and anxiety among the members?

"It's difficult to talk in group, but I believe everyone here has something to share that can help someone else." The statement, "It's difficult to talk in group, but I believe everyone here has something to share that can help someone else," decreases mistrust and anxiety among members who have difficulty with trust and feel anxious as a group of clients with chronic schizophrenia. The nurse conveys that each client is valuable and able to help someone else, thereby increasing the comfort and self-worth of each client.

A nurse is accompanying a client to the mall to do some shopping. A neighbor of the nurse approaches and tries to engage the nurse in conversation. What would be the most appropriate response by the nurse to the neighbor?

"Now is not a good time to talk. I will telephone you later." The nurse must not breach confidentiality. Indicating that the person accompanying the nurse is a client, even by saying "I am working," would be considered a breach of confidentiality.

A parent voices concern to the nurse that a 2-year-old toddler never seems to want to play with other children at the park. What would be the nurse's best response?

"That is considered normal at this age." Two-year-olds engage in parallel play, in which they play side by side but rarely interact. Associative play is characteristic of preschoolers, in which they are all engaged in a similar activity but with little organization. School-age children engage in cooperative play, which is organized and goal-directed. Children do not need to have play modeled for them. The ability to play and interact with other children will improve as the child grows.

The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH at 1700 each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?

0100, while sleeping. The client with diabetes mellitus who is taking NPH insulin in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping.

A palliative care nurse is caring for a client with end stage pancreatic cancer who is reporting severe pain. The healthcare provider orders morphine sulfate 4mg IV stat followed by morphine sulfate 2mg IV q 1h prn pain. The drug available in a multidose ampule of 2mg/mL. How many mL does the nurse administer for the initial dose? Record your answer as a whole number.

2 The ANA Code of Ethics for Nurses provision 3 states that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. This is crucial during medicating a palliative client. The initial dose ordered is 4 mg. The dose available is 2 mg. The quantity is 1mL. It is a multiple dose vial. 4mg/2 mg x 1 mL = 2 mL using the (dose ordered/units) x quantity method.

The nurse is caring for a 12 kg child diagnosed with epiglottitis. Vancomycin 50 mg/kg/day in three divided doses is prescribed. The medication is supplied as 500 mg/100 ml. How many milliliters per dose will the nurse administer? Record your answer using a whole number.

40 The child should receive 40 ml per dose. Here are the calculations: 50 mg/kg/day x 12 kg = 600 mg/day 600 mg/day ÷ 3 doses/day = 200 mg/dose 200 mg/dose ÷ 5 mg/ml = 40 ml/dose

A nurse is preparing to help a client with weakness in the right leg move from the bed to a wheelchair. Where should the nurse place the chair?

45 degrees to the bed on the left side The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall. The nurse should not place the chair perpendicular to the bed because the client won't be able to support weight on the right leg.

The nurse on the burn unit is caring for an adolescent with burns to the face and anterior neck, anterior chest, bilateral arms circumferentially, and the right anterior leg. Based on the Rule of Nines, calculate the body surface area that is burned. Record your answer using one decimal place.Rule of Nines Surface areaAnterior head 4.5%Posterior head 4.5%Anterior torso 18%Posterior torso 18%Anterior leg, each 9%Posterior leg, each 9%Anterior arm, each 4.5%Posterior arm, each 4.5%Genitalia/perineum 1%

49.5 The Rule of Nines is the standard for estimating total body surface area burned. To calculate: anterior head = 4.5% anterior chest (torso) = 18% both arms anterior and posterior - 9% each = 18% anterior right leg = 9% Total = 49.5%

An initial bolus of crystalloid fluid replacement for a child in shock is 20 ml/kg. The nurse is preparing to administer how many milliliters of fluid for a child weighing 30 kg?

600 mL Fluid volume replacement must be calculated using the child's weight to avoid overhydration. Initial fluid bolus is administered at 20 ml/kg, followed by another 20 ml/kg bolus if there is no improvement in fluid status.

An adolescent female arrives in the emergency department after a physical assault. How could the male nurse best protect the client's rights during the physical examination? Have a female health care worker present.

A female health care provider should be present to observe an examination performed by a male health care provider. Leaving the door open and informing the client's friends about her condition violates her right to privacy and confidentiality. Although the suspected attacker should be kept away from the examination room, having a female health care worker present during the examination best protects the girl's rights.

A client is a moderate risk for falling using a fall risk assessment scale. What should the nurse instruct the unlicensed assistive personnel (UAP) to do?

Activate the bed and chair alarms. The client has a moderate fall risk, and the nurse should direct the UAP to activate the bed and chair alarms. The UAP does not need to remain with the client during toileting unless the client's risk for falling is high. There is no evidence the client is confused, and hourly reorientation could disrupt sleep. Protective devices to restrain clients are used for clients at high risk for a fall and require a prescription from a health care provider.

The nurse is preparing a teaching plan for a client about crutch walking using a two-point gait pattern. What information should the nurse include?

Advance a crutch on one side, and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side.

A student nurse performed a urinary catheterization with a intra-partum client with the instructor present. The student nurse is asking if there is any legal recourse if there are complications from the procedure. What is the best response by the instructor? Select all that apply.

An attorney can summon all caregivers including students if there is legal concern. The student will be liable for any deviation from the procedure and failure to document. The documentation is supported by the institutional policy and procedure. An attorney can summon all caregivers including students if there is legal concern. The legal responsibilities are included the client's agreement to the urinary catheterization. The student and instructor have liability insurance and the student followed the institutional policy and procedure with the catheterization and the documentation. The staff nurse needs to be aware of the procedure because the staff nurse shares the assignment.

What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?

Antibiotics will need to be taken for 1 to 2 weeks. Treatment for cellulitis includes oral or intravenous antibiotics for 1 to 2 weeks, elevation of the affected extremity, and application of warm, moist packs to the site. Arm exercises help to reduce swelling, but do not treat the infection.

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse?

Ask the client to state name and birthdate. The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write the name and birthdate as the client has ataxia. Ataxia involves muscle movement, typically in the arms (making fine motor movements, such as writing, difficult) and legs, though speech may be slurred. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child?

Assess respiratory status frequently. Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as energy reserves are depleted; therefore, close monitoring is essential. Positioning the infant, monitoring fluid status, and including parents in care plan are necessary, but not the priority.

A client had surgery 6 hours ago. The client has a prescription for a narcotic for pain every 3 to 4 hours. The last dose was administered at 1500. When the nurse enters the room at 1800, the client is restless and grimacing. What action should the nurse take first?

Assess the client to determine the cause of the grimacing. The nurse should carefully assess the client to determine the reason for the grimacing and restlessness. The nurse should not assume by the client's nonverbal communication that the client is in pain and requires pain medication; the nurse must validate the message rather than making assumptions. The nurse should assess the client first before changing the client's position or turning down the lights.

A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next?

Call the surgeon. Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

A client who had an esophagogastrectomy performed 6 hours ago is confused and pulls out a nasogastric (NG) tube. Which action is the most important for the nurse to take regarding the NG tube?

Contact the surgeon to reinsert the NG tube. Because of the nature of the surgery, the prudent nurse would know that replacing the NG tube could create bleeding or open the internal sutures, leading to injury to the client. The nurse should contact the surgeon to replace the tube. Although documentation is important, it is not the most crucial action at the moment to address the client's needs. Leaving the NG tube out shows a lack of understanding of the client's problem.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?

There is no bleeding at the aspiration site. After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

A new client on the psychiatric unit has been diagnosed with depression and obsessive-compulsive personality disorder (OCPD). During visiting hours, her husband states to the nurse that he does not understand this OCPD and what can be done about it. What information should the nurse share with the client and her husband? Select all that apply.

Perfectionism and overemphasis on tasks usually interfere with friendships and leisure time. There are medicines, such as clomipramine or fluoxetine, that may help. Remind your wife that it is "OK" to be human and make mistakes. This disorder typically involves inflexibility and a need to be in control. Inflexibility, need to be in control, perfectionism, overemphasis on work or tasks, and a fear of making mistakes are common symptoms of OCPD. Clomipramine and fluoxetine may help with the obsessive symptoms. Interrupting the client's tasks is likely to increase her anxiety even more. Telling her that she cannot expect the family to be perfect is likely to create a power struggle.

A nurse is caring for a client at the local healthcare facility. Which ensures that legislation related to client confidentiality is implemented at the facility?

Place in private areas light boxes for examining x-rays with the client's name. The nurse should ensure that light boxes for examining x-rays with the client's name are located in private areas to ensure that client confidentiality measures are implemented at the facility. This will ensure that important client health details are not visible to personnel who are not involved in the client's healthcare. The client's name should not be displayed on the first page of all faxed records; the first page should indicate that the information in the statement is confidential. The nurse should not put up the client's health information on a whiteboard to be seen by other healthcare workers. End-of-shift reports to the nurse coming on duty should be presented in the client's room or other secure area, and they still need to be presented. .

A 9-month-old infant with eczema has lesions that are secondarily infected. Which recommendation is the most appropriate to help the parents best meet the needs of the child?

Play with the child every day. The parents can best meet the needs of their 9-month-old infant by playing with the child every day. All infants need time with their parents to develop trust and thus attain optimal development. The parents of a child with a chronic problem may need more guidance to meet the child's needs because of the focus on medical problems. The child's lesions are secondarily infected and therefore should not be contagious. Siblings do not need to stay away. Even with lesions that are infected, the child can still attend day care, but the child needs attention from the parents as well. Playing video games for several hours is not appropriate for a 9-month-old infant.

A client indicates readiness to look at the new colostomy. Which action would be most effective in preparing the client to look at the colostomy?

Use illustrated material during teaching sessions with the client. When a client demonstrates readiness to learn about the colostomy, it is usually best to start with simple techniques such as using illustrative material during teaching sessions. This will help the client visualize how the colostomy will appear.Although telling the client that normal body functions will continue and preparing the client for what the area will look like are both recommended, using illustrated material will better prepare the client for the sight of the colostomy.Visits from members of an ostomy club are very helpful, but these visits usually are more beneficial when the client already has knowledge of the colostomy and how it looks and functions.

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use?

Use of an infusion pump to regulate the flow rate Use of an infusion pump to regulate the flow rate is the appropriate safeguard, because infants and children are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a micro drop infusion set will not protect against fluid overload when I.V. administration is too rapid.

What is the nurse's most important intervention for a client having a tonic-clonic seizure?

Protect the client from further injury The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.

A client has acute arterial occlusion. The health care provider has prescribed IV heparin. What should the nurse do before starting the medication?

Review the blood coagulation laboratory values. Before starting a heparin infusion, it is essential for the nurse to know the client's baseline blood coagulation values (hematocrit, hemoglobin, and red blood cell and platelet counts). In addition, the partial thromboplastin time should be monitored closely during the process. The client's stools would be tested only if internal bleeding is suspected. Although monitoring vital signs such as apical pulse is important in assessing potential signs and symptoms of hemorrhage or potential adverse reactions to the medication, vital signs are not the most important data to collect before administering the heparin. Intake and output are not important assessments for heparin administration unless the client has fluid and volume problems or kidney disease.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which interventions should the nurse include? Select all that apply.

Tape all IV tubing connections securely. Weigh the client daily. Monitor the IV infusion rate hourly. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the IV fluid infusion rate hourly (even when using an IV fluid pump), and securely tape all IV tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the IV dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

A nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation. Why is this check so important?

The defibrillator will not deliver a shock if the synchronizer switch is turned on. The nurse needs to check the synchronizer switch to ensure the switch is turned off. The defibrillator will not deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on. The synchronizer switch should be turned on when attempting to terminate arrhythmias that contain QRS complexes, such as rapid atrial fibrillation that's resistant to pharmacologic measures. A synchronized shock should occur with the QRS complex, not the T wave, to avoid inducing ventricular fibrillation and allow for a lower shock dose.

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action?

Document this finding as on the high end of the normal range and plan to reassess. Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still within the normal range. It would be appropriate to reassess the client's heart rate because newborn heart rates can fluctuate depending on the state of consciousness/wakefulness, hunger, temperature, and especially if the newborn is moving or startled. It would be inappropriate to call the pediatrician or to notify the charge nurse at this time because the value is currently within the normal range.

The nurse is caring for a client with a panic disorder who is experiencing difficulty sleeping and is lingering at the nurses' station late at night. What nursing action is best?

Encourage the use of relaxation exercises or techniques. Relaxation exercises or techniques, such as deep breathing, progressive muscle relaxation, and imagery or relaxing visualization, can all help the client gain control over anxiety in a way that promotes sleep. These exercises help produce a physiologic response opposite to that produced by stress (i.e., the relaxation response). Providing sleeping pills such as zolpidem would provide short-term relief from the sleeplessness, but it would not promote healthy sleeping patterns. Suggesting the client talk or play pool would not help the client develop longer-term sleep habits or control stress or anxiety. Playing games and engaging in talk late into the evening may produce more of a stress response.

The nurse is planning staffing assignments for a group of clients. Which client is most appropriate for the nurse to assign to a nurse who normally works on the maternity unit?

a client who had an open appendectomy yesterday The nurse who usually works on a maternity unit has more experience with clients who have had abdominal surgery similar to a cesarean birth and should be assigned to a client who will closely match the nurse's experience level. The nurse should assign the client in halo traction to a nurse who has experience with the traction equipment. The client with cancer requiring ventilation and the client with progressing amyotrophic lateral sclerosis require care from a nurse who has more experience with clients with these needs.

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply.

a client with bacterial meningitis an older adult client with influenza Droplet precautions are used for clients with bacterial meningitis and influenza. The client with a positive staphylococcus wound culture needs contact precautions. The client receiving antibiotics for a fever after surgery will not require precautions. The client with the low white blood cell count will need neutropenic precautions.

The nurse teaches the three cardinal signs of choking and total airway blockage to the parents of a toddler who was treated for a foreign body obstruction. When asked to repeat the signs, the parents identify "turn blue" and "cannot speak." What third sign would the parents identify if teaching was successful?

collapses The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis), and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur. Gasping, a sudden intake of air, indicates that the child is still able to inhale. When a child is choking, air is not being exchanged, so gagging will not occur.

Several clients who work in the same building are brought to the emergency department. They all have fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate?

contact isolation with double-gloving and shoe covers The nurse should institute treatment for hemorrhagic fever viruses, including contact isolation with double-gloving and shoe covers, strict hand hygiene, and protective eyewear. The nurse should start respiratory isolation with negative pressure rooms, not positive pressure rooms. Enteric precautions are not needed because the virus is spread by droplet and contact. Reverse isolation protects the client; in this situation, the health care team also needs protection.

The client expressed to the nurse feelings of guilt and shame for contracting HIV/AIDS from an ex-partner 8 years ago, and although the client is feeling well, cannot develop healthy relationships. What priority action will the nurse implement during the client assessment?

depression screening The priority screening is for depression, since it frequently occurs in people with HIV/AIDS who experience guilt, sadness, lack of confidence, and a sense of worthlessness. Clients with serious depression are at risk for suicidal ideation and suicidal actions. Any of the other screenings for addiction, anxiety, and cognitive functioning may be useful to perform in the future.

The health care provider prescribes fluoxetine orally every morning for a 72-year-old client with depression. Which transient adverse effect of this drug requires immediate action by the nurse?

dizziness The presence of dizziness could indicate orthostatic hypotension, which may cause injury to the client from falling. Nausea, sedation, and dry mouth do not require immediate intervention by the nurse.

The nurse is teaching a group of teenage boys about the risks of chewing tobacco. The nurse should teach the boys to recognize which possible signs or symptoms of oral cancer? Select all that apply.

dysphagia unexplained mouth pain lump in the neck white patches on the mucosa Chewing tobacco has become a more common practice among teenagers. It is important that they understand that this increases their risk for oral cancer. They should be instructed to inspect their mouth frequently and report any observed lesions or other changes in the oral mucosa. Potential indicators of oral cancer are dysphagia, unexplained mouth pain, a lump in the neck, and white patches on the mucosa (leukoplakia). Other indications may be a painless mouth ulcer, a reddened patch (erythroplasia), and rough patches on the mucosa. Sensitive teeth and decreased saliva are not associated with oral cancer.

An adolescent client ingests a large number of acetaminophen tablets in an attempt to commit suicide. Which laboratory result is most consistent with acetaminophen overdose?

elevated liver enzyme levels Elevated liver enzyme levels, which could indicate liver damage, are associated with acetaminophen overdose. Metabolic acidosis isn't associated with acetaminophen overdose. An increased serum creatinine level may indicate renal damage. An increased WBC count indicates infection.

A client on the oncology floor requires a blood transfusion. The nurse ensures proper consent is obtained by taking what action?

ensuring client is aware of indications, risks, and alternatives to receiving blood products By definition, informed consent requires that clients are provided with information needed to make informed decisions about their health care. Although the nurse should witness the consent once the necessary information is provided, this witnessing of the client's signature is not the same as ensuring the client has the information needed to offer informed consent. Clients need information about their health care regardless of any religious beliefs. While policies can vary between jurisdictions, the primary health care provider is not the only individual who can legally obtain consent.

A community health nurse is planning to address the primary health needs of older adults living in their homes. What areas would the nurse assess first?

exercise patterns, nutrition, mobility, and safety Assessing exercise patterns, nutrition, mobility, and safety provides teaching regarding health promotion and illness and injury prevention for elderly clients living in their homes. It is important to ensure that elderly clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for elderly clients. Assessment of falls, injuries, and rehabilitation focuses only on mobility. Disease identification and management are important but do not address the most important factors that allow elderly clients to remain safe in their own homes. Medical visits are important, but they focus on health problems more than on meeting physical needs.

The nurse is late by over an hour when administering an antibiotic to a child being treated for a urinary tract infection. The antibiotic is prescribed to be given every 4 hours. What action should the nurse take after documenting the medication on the medication administration record?

fill out a medication error/occurrence report Failure to adhere to scheduled administration of a medication such as an antibiotic is a medication error. The nurse should complete a medication error/occurrence report. The nurse should also notify the charge nurse of the error but does not need to do this prior to initiating the proper paperwork. The nurse should adjust the time of the next dose to get the schedule back on track but does not need to involve the pharmacy to do this. The monitoring of the child's response would be done regardless of the time the medication was administered, so it is not relevant to this scenario.

A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit?

firm fundus when gentle massage is used The priority assessment is that the client has a firm fundus when gentle massage is used. This indicates that the client's fundus may be soft or "boggy" when it is not massaged. The receiving nurse should assess the client's fundus soon after admission and continue to monitor the client's fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal. The temperature and pulse are within normal limits.

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

health habits, family relationships, affect, and thought patterns A psychosocial assessment involves assessment of health habits, family relationships, emotional responses, and thought patterns. These areas are important to assess to determine how the client is coping with illness. It is also important to identify the support systems of the client. Each of the other choices includes physical assessment factors, not just psychosocial factors.

An infant is having a 2-month checkup at the pediatrician's office. The physician tells the parents that the infant is being assessed for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of the:

hip. To assess for Ortolani's sign, the physician abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.

A client has been taking fluoxetine, 40 mg daily at 0900 for 1 week. The client states he feels nervous and has had diarrhea. What interpretation does the nurse make about the client's symptoms?

important, probably suggesting a decrease in dosage or change to another medication Anxiety and diarrhea are adverse effects of fluoxetine and may be relieved by a decrease in dosage. It may be necessary to change to another selective serotonin reuptake inhibitor or to a different class of antidepressants. All reports of adverse effects from medication are important to evaluate. The discomfort experienced by the client could lead to medication noncompliance and dehydration. The client's symptoms alone do not indicate a worsening of depression. A worsening of the depression would be characterized by a more depressed mood, inability to experience pleasure, and appetite disturbances. Diarrhea is not a symptom of depression. Increasing the dose of fluoxetine at this point could worsen the adverse effects, not improve them.

A nurse is providing care to a 5-year-old child with a fractured femur whose nursing diagnosis is imbalanced nutrition: less than body requirements. Which nutritional change is most likely to occur with this condition?

increased carbohydrate need Increased carbohydrate need is most likely because healing and repair of tissue requires more carbohydrates.

The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest who has difficulty breathing. What is the priority intervention?

intubation Intubation is performed to maintain a patent airway. Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracentesis are performed to relieve a pneumothorax.

A client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure (BP) of 220/120 mm Hg. Which prescription by the health care provider should the nurse question?

labetalol drip to keep the blood pressure <120/80 mm Hg The nurse should question the prescription to administer labetalol to decrease the blood pressure to <20/80 mm Hg. It is not recommended that diastolic blood pressure is <90 mm Hg. Mean arterial pressure (MAP) should be kept between 80 and 110 mm Hg. The client's presenting BP is 220/120 mm Hg, which would indicate a MAP of 146. When a client has a stroke, autoregulation is a protective mechanism use to protect the brain. An elevated blood pressure helps to increase cerebral perfusion. The standard of care is to administer tissue plasminogen activator (tPA) within 4.5 hours of signs and symptoms of a stroke. Normal saline is an isotonic solution recommended for a client experiencing an ischemic stroke. Keeping the head of the bed at 30 degrees helps to decrease intracranial pressure.

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:

massages the client's legs. Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems.Ambulation, elasticized stockings, and moving the legs in bed all help reduce the risk of thrombophlebitis.

Which nursing intervention is the highest priority when a client is placed in restraints?

monitoring the client every 15 minutes Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

A client with schizophrenia displays a lack of interest in activities, reduced affect, and poor ability to perform activities of daily living. What term would be used to describe this clustering of symptoms?

negative symptoms Schizophrenic clients commonly display positive and negative symptoms. Negative symptoms are characterized by the absence of typically displayed emotional responses. Clients with these symptoms tend to respond poorly to medication. Positive symptoms, such as auditory or visual hallucinations, are characterized by enhancement of a sensory modality. These aren't physiologic symptoms of schizophrenia. Extrapyramidal symptoms may result from long-term antipsychotic drug use in schizophrenics.

What is an expected finding in a client with adrenal crisis (Addisonian crisis)?

pain Adrenal hormone deficiency can cause profound physiologic changes. The client may experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention causes decreased, not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances, including nausea and vomiting, are expected findings in Addison's disease, not hunger.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.

pepperoni pizza bacon cheese soft drinks Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.

When caring for a toddler with epiglottitis, the nurse should first:

place a tracheotomy tray at the bedside. Placing a tracheotomy tray at the bedside should take priority because acute epiglottitis is an emergency situation in which inflammation can cause the epiglottis to swell, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation. The nurse should never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottitis are present because this maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are the priority. Only after a patent airway is secured can antibiotics be given to treat Haemophilus influenzae, a common cause of acute epiglottitis.

Which client requires immediate nursing intervention? The client who

presents with a rigid, boardlike abdomen. A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating may indicate a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. A client with a large-bowel obstruction may have ribbonlike stools.

After a gastrectomy, the client has a nasogastric (NG) tube in place. The tube is used to:

prevent excessive pressure on suture lines. Nasogastric suctioning is prescribed to remove accumulated gas or fluid (secretions). Excessive fluid can cause pressure on suture lines, resulting in injury, rupture, or dislodgment. The gastrointestinal tract should remain empty (no food or fluids) until peristalsis returns and suture lines have healed adequately, at which time the NG tube is removed.Ascitic fluid collects in the peritoneal space, not the stomach.Enteral feedings in the immediate postoperative period would be inappropriate.Antacids are not used to promote healing of suture lines.

A physician orders lithium for a client diagnosed with bipolar disorder. The nurse needs to provide appropriate education for the client receiving this drug. Which topics should the nurse cover? Select all that apply.

signs and symptoms of drug toxicity the need to report for laboratory testing to monitor blood levels changes in mood may take 7 to 21 days Client education should cover the signs and symptoms of drug toxicity as well as the need to report them to the physician. The client should be instructed to report for follow-up laboratory studies to monitor the client's lithium level to avoid toxicity. The nurse should explain that it may take 7 to 21 days before the client notes a change in the client's mood. Lithium doesn't have addictive properties. Tardive dyskinesia isn't an adverse effect of lithium. Tyramine is a potential concern for clients taking monoamine oxidase inhibitors.

A client has a history of schizophrenia. Because of a history of noncompliance with antipsychotic therapy, the client will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in the teaching plan?

sitting up for a few minutes before standing to minimize orthostatic hypotension The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may not become evident for several weeks. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately.

A nurse is working with a group of parents whose children have died from cystic fibrosis. The group is talking about "acceptance." Two parents discuss their unwillingness to accept their child's death. The nurse should understand that:

some individuals find the idea of "accepting" the death of a loved one unachievable. Although acceptance is considered to be the final stage of grief, some deaths, including out-of-life-cycle deaths, may never be accepted. To insist that a parent should work toward this goal would not likely be helpful. Rather it would be beneficial for the nurse to explore the parents' relationship with their deceased child. There is no evidence that these parents are experiencing denial or need more support from the group. Assuming that an individual isn't at the right stage is unreasonable and presumptuous, given the considerable variations in people's responses to loss.

Which client is at highest risk for colorectal cancer?

the client who has been treated for Crohn's disease for 20 years Clients over age 50 who have a history of inflammatory bowel disease are at risk for colon cancer. The client who smokes is at high risk for lung cancer. While the exact cause is not always known, other risk factors for colon cancer are a diet high in animal fats, including a large amount of red meat and fatty foods with low fiber, and the presence of colon cancer in a first-generation relative.

A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first?

the client who suffered an acute myocardial infarction (MI) who is complaining of constipation The client who suffered an acute MI who is complaining of constipation should be addressed first. If the client strains at stool after an MI, the vagal response may be stimulated, causing bradycardia thereby provoking arrhythmias. After addressing the MI client with constipation, the nurse should promptly address the pain-relief needs of the client who had a pacemaker inserted the previous day. The nurse should delegate answering the call light to the ancillary personnel. The nurse may also delegate some of the discharge preparation, such as packing the client's belongings.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

tretinoin Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

A nurse manager is implementing a plan to improve the use of standard precautions by the staff on the unit. After collecting observational data on the staff's use of personal protective equipment, which behavior would the nurse manager identify as an indication of the need for education? Select all that apply.

use of gowns when caring for every client use of sterile gloves for urine specimen collection recapping of needles after use Standard precautions include using gowns if there will be splashing or spattering of blood or body fluids (not for every client), using clean (not sterile) gloves to collect urine specimens, and never recapping needles once used. Standard precautions include performing hand hygiene after removing gloves and disposing of contaminated dressings in the proper biohazard container. These behaviors do not indicate a need for education.

A number of clients have come to the emergency department after a possible terrorist act involving arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply.

violent vomiting severe diarrhea abdominal pain When arsenic overexposure occurs, the symptoms include violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. Dehydration can lead to shock and death.After the acute phase, bone marrow depression, encephalopathy, and sensory neuropathy occur.A persistent cough is not a sign of arsenic exposure.

A 2-year-old child is brought into the clinic with an upper respiratory tract infection. The nurse is concerned about abuse with this child. Which findings should prompt the nurse to evaluate for suspected child abuse? Select all that apply.

welts or bruises in various stages of healing on the trunk circular, symmetrical burns on the lower legs a parent who is hypercritical of the child and pushes the frightened child away Injuries at various stages of healing in protected or padded areas can be signs of inflicted trauma, leading the nurse to suspect abuse. Burns that are bilateral as well as symmetrical and regular are typical of child abuse. The shape of the burn may resemble the item used to create it, such as a cigarette. When a child is burned accidentally, the burns form an erratic pattern and are usually irregular or asymmetrical. Pushing the child away and being hypercritical are typical behaviors of abusive parents. Superficial scrapes and bruises on the lower extremities are normal in a healthy, active child. A deep blue-black macular patch on the buttocks is more consistent with a Mongolian spot than a traumatic injury that would suggest abuse.