NCLEX practice questions

The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care? 1. Wound care 2. Pain control measures 3. Measurement of intake 4. Cold and heat applications

Answer: 1 The most common complications associated with orchiopexy are bleeding and infection. Discharge instruction should include demonstrating wound cleansing and dressing and teaching parents to identify signs of infection, such as redness, warmth, swelling, or discharge. Testicles will be held in a position to prevent movement, and great care should be taken to prevent contamination of the suture line. Analgesics may be prescribed but are not the priority, considering the options presented. Measurement of intake is not necessary. Cold and heat application is not a prescribed treatment measure.

The nurse has a prescription to administer bethanechol chloride subcutaneously. Before giving this medication, the nurse checks to ensure that which condition is not noted in the client's history? 1. Asthma 2. Lung infection 3. Hypothyroidism 4. Urinary retention

Answer: 1 Bethanechol chloride is a cholinergic medication that is used for urinary retention. This medication should not be used for clients with asthma because it can precipitate bronchoconstriction by activating muscarinic receptors. Other conditions this medication should not be used with include hypotension, bradycardia, gastric ulcers, intestinal obstruction, urinary tract obstruction, and hyperthyroidism.

The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? 1.Apply an occlusive dressing. 2.Reinsert the chest tube quickly. 3.Contact the respiratory therapist. 4.Contact the health care provider (HCP).

Answer: 1 If a chest tube is accidentally pulled out, the nurse would immediately apply an occlusive dressing and then contact the HCP. It is not appropriate and not a nursing role to reinsert a chest tube. It is not necessary to contact the respiratory therapist. The HCP needs to be notified, but this is not the initial nursing action.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

Answer: 1 Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communication, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Option 2 is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Option 4 can be seen as degrading.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date.

Answer: 1, 2 A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. 1. Physical therapy 2. Knee immobilizer 3. Aspiration of joint fluid 4. Ambulation with a walker 5. Antiinflammatory medications

Answer: 1, 2, 3, 5 The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, antiinflammatory medications, rest, ice, and possibly reconstructive surgery.

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet 2. Teaching the child effective hand-washing techniques 3. Scheduling playtime in the playroom with other children 4. Notifying the health care provider (HCP) if jaundice is present 5. Instructing the parents to avoid administering medications unless prescribed 6. Arranging for indefinite home schooling because the child will not be able to return to school

Answer: 1, 2, 5 Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand washing is the most effective measure for control of hepatitis in any setting, and effective hand washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

The nurse is caring for a client with chronic kidney disease. The nurse knows that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply. 1.Help regulate blood pressure. 2.Encourage immunosuppression. 3.Stimulate liver to secrete enzymes. 4.Assist to regulate acid-base balance. 5.Convert vitamin D to an active form. 6.Produce erythropoietin for red blood cell synthesis.

Answer: 1, 4, 5, 6 Besides maintaining urinary elimination, the kidneys are also involved with helping to regulate blood pressure, assisting in regulating acid-base balance, converting vitamin D to an active form, and producing erythropoietin for red blood cell synthesis. The kidneys do not encourage immunosuppression and do not stimulate the liver to secrete enzymes.

In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. 1. Control of symptoms during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature on rising in the morning that remains throughout the day

Answer: 1,2,3,4 Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, an improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

Answer: 1,2,3,5 Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.

A client is scheduled for angioplasty. The client says to the nurse, "I'm so afraid that it will hurt and will make me worse off than I am." Which response by the nurse is therapeutic? 1. "Can you tell me what you understand about the procedure?" 2. "Your fears are a sign that you really should have this procedure." 3. "Those are very normal fears, but please be assured that everything will be okay." 4. "Try not to worry. This is a well-known and easy procedure for the health care provider."

Answer: 1. "Can you tell me what you understand about the procedure?" This option explores client's feelings, determines level of client understanding about the procedure, and displays caring.

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? 1. "This is mostly used in a walk-in clinic or emergency department." 2."This is focused on disease detection and conducted in a health care provider's office." 3."This is conducted on admission in a primary care or long-term care setting." 4."This is conducted as a follow-up examination by a health care provider."

Answer: 1. "This is mostly used in a walk-in clinic or emergency department." A problem-based assessment involves a history and physical examination that is limited to a specific problem or client complaint and is most often used in a walk-in clinic or emergency department. A screening assessment is a limited examination focused on disease detection. A complete assessment includes a complete health history and physical examination and forms a baseline database. It is performed on admission to a primary care or long-term care setting. An episodic or follow-up assessment is done when a client is being followed up for a previously identified or treated problem.

OH BOY DIGOXIN IS REAL The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception

Answer: 1. Anorexia Digoxin: cardiac glycoside used to manage/treat HF and control ventricular rates in clients with a-fib Common early signs of toxicity: GASTRO: anorexia, nausea, vomiting NEURO: headache, depression, weakness, drowsiness, confusion, nightmares Non-early signs: facial pain, personality changes, ocular disturbances (photophobia, diplopia, light flahses, halos around objects, yellow/green color perception)

A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action? 1. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid 2. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid 3. Tilts the head back, pulls down on the lower lid, and puts the drop in the lower lid 4. Lies with head to the right, puts the drop in the inner canthus, and slowly turns to the left while blinking

Answer: 1. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid It is correct procedure for the client to lie down or sit with his or her head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that one drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. With the eye closed, the client squeezes the drop onto the inner canthus of the eye. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.

The nurse notes blanching, coolness, and edema at the peripheral IV site. On the basis of these findings, the nurse should implement which action? 1. Remove the IV 2. Apply a warm compress 3. Check for blood return 4. Measure the area of infiltration

Answer: 1. Remove the IV The client is experiencing an infiltration Infiltration can be damaging to surrounding tissue Removing the IV prevents any further damage

The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms? 1. The danger time has passed. 2. Signs may appear at any time. 3. The next hour could be critical. 4. Withdrawal has likely already started.

Answer: 2 Alcohol withdrawal is most likely to occur within the first 6 to 8 hours after abrupt cessation; however, it can occur over the next several days. Therefore, the option suggesting the danger has passed as well as the one suggesting that a specific time can be predicted can be eliminated. The option that withdrawal has already started is not supported by the information presented.

Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate? 1.Folic acid 2.Phenytoin 3.Bupropion 4.Methyldopa

Answer: 2 An antiseizure medication (specifically phenytoin) taken during pregnancy is a known risk factor in the development of cleft lip and cleft palate. Folic acid use is recommended during pregnancy to reduce the risk of cleft lip and palate. The use of an antidepressant (bupropion) has not been found to increase a woman's risk of developing a fetus with cleft lip or palate. Although bupropion can be used for smoking cessation, and maternal smoking can contribute to the development of cleft lip, taking bupropion does not increase a woman's risk of having a fetus affected by cleft lip or palate. Methyldopa may be used during pregnancy for maintenance in women with chronic hypertension.

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? 1. Flashlight 2. Snellen chart 3. Reflex hammer 4. Ophthalmoscope

Answer: 2 Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An ophthalmoscope is used to examine the retina.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge

Answer: 2 Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.

A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the health care provider to prescribe? 1.Increase intake of water with a diet high in carbohydrates. 2.Consume oral rehydration fluid, advancing to a regular diet. 3.Begin fluid replacement immediately with intravenous fluids. 4.Begin a diet of bananas, rice, apples, pears, and toast with juice.

Answer: 2 Mild dehydration is usually treated at home and consists of age-appropriate diet along with oral rehydration fluids. Bananas, rice, apples, pears, and toast with juice can be irritating to the gastrointestinal (GI) tract and does not provide the rehydration needed in a child who is dehydrated. Water does not provide electrolyte fluid replacement, a need during dehydration. Hospitalization and intravenous fluids is not required with mild dehydration.

The nurse developing a teaching plan for a client being prescribed phenelzine sulfate should instruct the client to avoid which item? 1. Vasodilators 2. Aged cheeses 3. Digitalis preparations 4. Cherries and blueberries

Answer: 2 Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. A client taking an MAOI must avoid foods that contain tyramine such as aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. Other food items to avoid include chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. Clients taking MAOI medications also should avoid levodopa and meperidine. The items identified in the other options need not be avoided.

The nurse educator is providing in-service education to the nursing staff regarding trans cultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response? 1. "A group of individuals identifying as a part of the Iroquois tribe among Native Americans." 2. "A person who moves from China to the U.S. and learns about and adapts to the culture in the U.S." 3. "A group of individuals living in the Azores that identify autonomously but are part of the larger population of Portugal." 4. "A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his/her cultural group."

Answer: 2 Acculturation is a process of learning a different culture to adapt to a new or changing environment. Options 1, 3 describe a subculture. Option 4 describes an ethnic identity.

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly 2. Arrange for an interpreter to translate 3. Speak to the client and family together 4. Stand close to the client and speak loudly

Answer: 2 Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 & 4 are inappropriate and ineffective ways to communicate. Option 3 is incorrect because it violates privacy and does not ensure correct translation.

A pregnant client calls the nurse at the health care provider's office and reports that she has noticed a thin, colorless vaginal drainage. Which information is most appropriate for the nurse to provide to the client? 1. Come to the clinic immediately. 2. The vaginal discharge may be bothersome but is a normal occurrence. 3. Report to the emergency department at the maternity center immediately. 4. Use tampons if the discharge is bothersome but be sure to change the tampons every 2 hours.

Answer: 2 Many pregnant clients notice an increased thin, colorless or yellow vaginal discharge throughout pregnancy. The increase in the amount of discharge may be bothersome, but it is usually a normal occurrence. This occurrence does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, panty liners may be desirable. The client should not use tampons, because they may increase the likelihood for development of an infection or toxic shock syndrome. If panty liners are used, they should be changed frequently.

The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply. 1. Obtain throat culture 2. Ensure patent airway 3. Prepare child for chest X-ray 4. Maintain the child in a supine position 5. Obtain a pediatric-size tracheostomy tray 6. Place the child on an oxygen saturation monitor

Answer: 2,3,5,6 Epiglottitis: serious obstructive inflammatory process that requires immediate intervention, airway patency is a priority. Examination of the throat/collecting culture is contraindicated because it can precipitate further obstruction. Lateral neck/chest X-ray obtained to determine degree of obstruction, if any. Should remain in an upright position to reduce respiratory distress. Placed on oxygen sat. monitor to monitor oxygenation status. Trach and intubation may be necessary if respiratory distress is severe.

A client with renal insufficiency has a magnesium level of 3.5 mEq/L (1.75 mmol/L). On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity

Answer: 2. Drowsiness Normal magnesium levels: 1.5-2.5 mEq/L (0.75-1.25 mol/L) 3.5 mEq/L indicates hypermagnesemia Hypermagnesemia leads to neurological manifestations (neurological depression): drowsiness, sedation, lethargy, respiratory depression, muscle weakness, areflexia. Bradycardia and hypotension also occur

The nurse should place the client in which position to administer an enema? 1. Prone 2. Left side-lying (Sims') with right knee flexed 3. Dorsal recumbent 4. Supine

Answer: 2. Left side-lying (Sims') with right knee flexed This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum Improves retention of solution

An MRI study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter 2. Remove all metal-containing objects from the client 3. Keep the client NPO for 6hrs before the test 4. Instruct client in inhalation techniques for the administration of the radioisotope

Answer: 2. Remove all metal-containing objects from the client All metal objects (rings, bracelets, hairpins, watches) should be removed. Obtain history to know whether the client has any internal metallic devices (orthopedic hardware, pacemakers, shrapnel)

A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? 1. Protein 2. Glucose 3. Amylase 4. Cholesterol

Answer: 3 Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Didanosine is toxic to the pancreas and the liver. A serum amylase level that is increased by 1.5 to 2 times normal may signify pancreatitis and may be fatal in the client with AIDS. Therefore, the nurse should monitor the results of amylase and liver function studies closely. Alterations in protein, glucose, and cholesterol levels are unrelated to this medication.

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 1. Tearful, self-isolated 2. Affect bland, withdrawn 3. Fist clenched, pounding table, fearful 4. Temperature 98.4°F (36.8°C); respirations 18 breaths/min

Answer: 3 Anxiety signs and symptoms may take a physical form and if abnormal should be addressed as a priority for the client. A temperature of 98.4°F and respirations 18 breaths/min are normal vital signs. Tearfulness, self-isolation, a bland affect, and a withdrawn state are abnormal findings but are commonly associated with anxiety. These findings are not life-threatening, although they should be monitored. Fist clenched, pounding the table, and exhibiting fear indicate a possible threat to safety of the client or others.

A client has been given a prescription for benzonatate. Which observation should the nurse look for to evaluate the effectiveness of the medication? 1. Increasing the client's comfort level 2. Decreasing the client's anxiety level 3. Calming the client's persistent cough 4. Eliminating the client's nausea and vomiting

Answer: 3 Benzonatate is a locally acting antitussive that decreases the intensity and frequency of cough without eliminating the cough reflex. The other options are not intended effects of this medication.

A community health nurse is providing an educational session on cancer of the cervix for women living in the community. The nurse informs the community residents that which is an early sign of this type of cancer? 1. Abdominal pain 2. Constant and profuse bleeding 3. Irregular vaginal bleeding or spotting 4. Dark and foul-smelling vaginal drainage

Answer: 3 Early cancer of the cervix usually is asymptomatic. The 2 chief symptoms are leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. The vaginal discharge increases gradually in amount and becomes watery and finally dark and foul-smelling because of necrosis and infection of the tumor mass. As the disease progresses, the bleeding may become constant and may increase in amount.

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1.Heart failure 2.Pulmonary edema 3.Cardiogenic shock 4.Aortic insufficiency

Answer: 3 IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of IABP therapy is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema.

A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L. How should the nurse interpret this finding? 1.A negative test 2.A positive test 3.Suggestive of CF 4.An unrelated finding

Answer: 3 In a sweat test, sweating on the infant's forearm is stimulated with pilocarpine, the sample is collected on absorbent material, and the amount of sweat chloride is measured. A chloride level higher than 60 mEq/L (60 mmol/L) is considered to be a positive test result. A sweat chloride level lower than 40 mEq/L (40 mmol/L) is considered normal. A sweat chloride level higher than or equal to 40 mEq/L (40 mmol/L) is suggestive of CF and requires a repeat test. Options 1, 2, and 4 are incorrect interpretations of the test results.

The nurse provides instructions to the mother of a child with mumps regarding respiratory precautions, and the mother asks the nurse about the length of time required for the respiratory precautions. The nurse should make which statement to the mother? 1."Precautions are not necessary once the swelling appears." 2."Precautions are not necessary before the swelling begins." 3."Precautions are indicated during the period of communicability." 4."Precautions are indicated for 20 days following the onset of parotid swelling."

Answer: 3 Mumps is transmitted via direct contact with or droplet spread from an infected person. Droplet precautions are indicated during the period of communicability (immediately before and after swelling begins); therefore, all other options are incorrect.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider (HCP). 4. Encourage increased oral intake of fluids.

Answer: 3 Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? 1.Provide pin care. 2.Medicate the client. 3.Call the health care provider. 4.Remove 2 pounds (0.9 kg) of weight from the traction system.

Answer: 3 Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids

Answer: 3 The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by UAPs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

The health care provider writes prescriptions for a client with chronic kidney disease (CKD). Which prescription should the nurse question? 1.Insert a saline lock. 2.Obtain a daily weight. 3.Provide a high-protein diet. 4.Administer a calcium supplement with each meal.

Answer: 3 When a client experiences CKD, the blood urea nitrogen (BUN) and serum creatinine levels rise. The client also experiences increased potassium, increased phosphates, and decreased calcium. BUN and creatinine are the byproducts of protein metabolism, so monitoring protein intake is important, with care taken to include proteins of high biological value. Clients with CKD will have protein restricted early in the disease to preserve kidney function. In end-stage disease, protein is restricted according to the client's weight, the type of dialysis, and protein loss. With CKD, the nurse is concerned about fluid volume overload and accumulation of waste products. Because of the kidneys' inability to excrete fluid, it is important for the nurse to prevent as well as assess for early signs of fluid volume excess. Infusing an intravenous (IV) solution into a client with CKD significantly increases the risk for overload. If an IV access is needed, it usually involves only a saline lock. Obtaining the client's daily weight is one of the most important assessment tools for evaluating changes in fluid volume. The kidneys also are responsible for removing waste products. The client also receives phosphate binders, calcium supplements, and vitamin D to prevent bone demineralization (osteodystrophy) from chronically elevated phosphate levels.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

Answer: 3 Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety.

The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is needed if the mother states that she will include which food item in the child's nutritional plan? 1. Corn 2. Chicken 3. Oatmeal 4. Vitamin supplements

Answer: 3 Oatmeal Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

The nurse prepares to care for a client on contact precautions who has a HAI caused by methicillin resistant Staphylococcus aureus (MRSA). The client has an abdominal wound wound that requires irrigation and has a tracheostomy attached to a mechanical ventiatior, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client's room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors

Answer: 3. Gloves, gown, face shield Must consider methods of possible transmission of infection, based on client's condition Splashes of infective material can occur during wound irrigation/trach. suctioning

The nurse is choosing age-appropriate toys for a toddler, which toy is the best choice for this age? 1. Puzzle 2. Toy soldiers 3. Large stacking blocks 4. A card game with large pictures

Answer: 3. Large stacking blocks Toddlers like to master activities independently Do not have developmental ability to determine what can be harmful (puzzle/toy soldier: small pieces can be choking hazard)

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift

Answer: 4 Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy." 2. "I should lower my blood volume by limiting my fluids." 3. "I should maintain a low-calorie diet to prevent any weight gain." 4. "I should drink adequate fluids and increase my intake of high-fiber foods."

Answer: 4 Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium should be restricted as prescribed by the health care provider because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.

A client has been prescribed dextroamphetamine. The client complains to the nurse that the client cannot sleep well at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which proper time schedule? 1. 2 hours before bedtime 2. After supper each night 3. Just before going to sleep 4. At least 6 hours before bedtime

Answer: 4 Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent sleep disturbance.

A client is on enalapril for the treatment of hypertension. The nurse teaches the client to seek emergent care if which is experienced? 1.Nausea 2.Insomnia 3.Dry cough 4.Swelling of the tongue

Answer: 4 Enalapril is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side, not adverse, effects of the medication.

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time? 1.Retest the pH using another strip. 2.Document that the nasogastric tube is in the correct place. 3.Check for placement by auscultating for air injected into the tube. 4.Call the health care provider to request a prescription for a chest radiograph.

Answer: 4 If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach. Based on this information, the nurse should call the health care provider to request a prescription for a chest radiograph to determine if placement is accurate. Retesting the pH using another strip is unnecessary and checking for placement by auscultating for air injected into the tube is not a definitive method of checking for tube placement. The nurse should not document that the tube is in the correct place because the data indicate this may not be the case.

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? 1. "I don't like my figure anymore. My clothes are all too tight." 2. "I don't like my breasts anymore. These silver lines are ugly." 3. "I don't like my stomach anymore. That brown line is disgusting." 4. "I don't like my face anymore. I always look like I have been crying."

Answer: 4 In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent.

The health care provider is planning to prescribe a medication for a client with major depression. Which medication should the nurse expect to be prescribed? 1. Diazepam 2. Lorazepam 3. Phenobarbital 4. Paroxetine hydrochloride

Answer: 4 Paroxetine is an antidepressant used in the treatment of major depression. Diazepam and lorazepam are benzodiazepines and are used to treat anxiety. Phenobarbital is a barbiturate used for the short-term treatment of insomnia.

A client who is scheduled to have warfarin sodium therapy has a prothrombin time (PT) of 28 seconds (28 seconds). What is the most appropriate nursing intervention at this time? 1.Give double the dose. 2.Administer the next dose. 3.Give half of the next dose. 4.Call the health care provider (HCP).

Answer: 4 The PT is one test that may be used to monitor warfarin sodium therapy. The international normalized ratio is another laboratory test used to monitor warfarin therapy. The normal PT is 11 to 12.5 seconds (11 to 12.5 seconds). A PT of 28 seconds represents an elevated value. The nurse should withhold the next dose and notify the HCP. A medication dose should not be changed without a specific prescription (options 1 and 3).

What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia? 1.Their child will very likely experience difficulty in school. 2.The prognosis for their child is good because he is so young. 3.With medication, their child is not likely to experience relapses. 4.Their child will be treated for an imbalance of the chemical dopamine.

Answer: 4 The dysregulation theory regarding the cause of schizophrenia shows a relationship between the brain levels of dopamine and the symptoms of schizophrenia. The prognosis is negatively affected when the onset of symptoms occurs during the adolescent years. Although medication compliance is a strong factor in minimizing the recurrence of relapses, it is not the only factor that has an effect. Moreover, although schizophrenia has an effect on reasoning and perception, the likelihood of experiencing difficulty in school is not certain.

A client has a tumor that is interfering with the function of the hypothalamus. The nurse should monitor for signs and symptoms related to which imbalance? 1.Melatonin excess or deficit 2.Glucocorticoid excess or deficit 3.Mineralocorticoid excess or deficit 4.Antidiuretic hormone (ADH) excess or deficit

Answer: 4 The hypothalamus exerts an influence on both the anterior and the posterior pituitary gland. Abnormalities can result in excess or deficit of substances normally mediated by the pituitary. ADH could be affected by disease of the hypothalamus because the hypothalamus produces ADH and stores it in the posterior pituitary gland. The pineal gland is responsible for melatonin production. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

The nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid balance if which 24-hour intake and output totals are noted? 1. Intake 1500 mL, output 800 mL 2. Intake 3000 mL, output 2000 mL 3. Intake 2400 mL, output 2900 mL 4. Intake 1800 mL, output 1750 mL

Answer: 4 For the client on a normal diet, the normal fluid intake is approximately 1200 to 1800 mL of measurable fluids per day. The client's output in the same period should be about the same and does not include insensible losses, which are extra. Insensible losses are offset by the fluid in solid foods, which also is not measured.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1.A client who is ambulatory demonstrating steady gait 2.A postoperative client who has just received an opioid pain medication 3.A client scheduled for physical therapy for the first crutch-walking session 4.A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C)

Answer: 4 The nurse should plan to care for the client who has an elevated white blood cell count and a fever first because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

A client with coronary artery disease has selected guided imagery to help cope with psychosocial stress. Which client statement indicates an understanding of this stress reduction measure? 1. "This will help only if I play music at the same time" 2. "This will work for me only if I am alone in a quiet area" 3. "I need to do this only when I lie down in case I fall asleep" 4. "The best thing about this is that i can use it anywhere"

Answer: 4. "The best thing about this is that I can use it anywhere" Guided imagery: client creates image in the mind, concentrating on the image, gradually becoming less aware of the offending stimulus Can be done any time, anywhere Some may use other techniques or play music with it

A client with Parkinson's disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use wheelchair to move around 2. Stand erect and use cane to ambulate 3. Keep the feet close together while ambulating and use a walker 4. Consciously think about walking over imaginary lines on the floor

Answer: 4. Consciously think about walking over imaginary lines on the floor Clients with Parkinson's disease develop bradykinesia (slow movement) or akinesia (freezing/no movement) Having client imagine lines on floor to walk over can keep them moving forward while remaining safe

The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive SQ insulin before breakfast 2. The client who has an NG tube attached to intermittent suction 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50mg/dL (2.8 mmol/L) and complains of blurred vision

Answer: 4. the client who has a blood glucose level of 50/mg/dL (2.8 mmol/L) and complains of blurred vision The client has low blood glucose and symptoms of hypoglycemia Must be assessed and stabilized before the other clients (prioritizing)

Client Chart Hx/Physical: -item 1: Has renal calculi -Item 2: Had thrombophlebitis 1 year ago Medications: -item 3: Multivitamin orally daily Diagnostic Results: -item 4: Electrocardiogram normal The nurse reviews the history and physical examination document documented in the medical record of a client requesting a prescription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented item? Refer to chart above.

Answer: item 2: had thrombophlebitis 1 year ago Oral contraceptives are contraindicated in women with a history of: -thrombophlebitis -thromboembolic disorders -cardiovascular disease -cerebrovascular disease (includes stroke) -estrogen-dependent cancer or breast cancer -benign/malignant liver tumors -impaired liver function -hypertension -diabetes mellitus with vascular involvement Adverse effects of oral contraceptives: -increased risk of superficial/DVT -pulmonary embolism -thrombotic stroke (other types of stroke) -MI -accelerations of preexisting breast tumors

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina? 1. It is most effectively managed by beta-blocking agents. 2. It has the same risk factors as stable and unstable angina. 3. It can be controlled with a low-sodium, high-potassium diet. 4. Generally it is treated with calcium channel-blocking agents.

Answer : 4 Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium channel blockers. Beta blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated.

An older client with rheumatoid arthritis has been instructed by the health care provider to take ibuprofen 400 mg orally (PO) three times daily. The home care nurse reading the medication prescription knows that the instruction has been effective when the client states the instructed dose is which? 1.The normal adult dose 2.Higher than the normal adult dose 3.An unusual dosage for this diagnosis 4.Two times higher than the normal adult dose

Answer: 1 For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose for an older client is 400 to 800 mg three or four times daily. The other options are incorrect.

The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care? 1.Infection 2.Poor body image 3.Decreased urinary elimination 4.Cracking oral mucous membranes

Answer: 1 Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord. There is no membrane covering the exposed bowel. Surgical repair will be done as soon as possible because of the risk of infection in the unprotected bowel. Therefore, the greatest risk immediately after delivery is infection. Because the client is a neonate, poor body image is not an immediate problem. Impaired urinary elimination is unlikely because the gastrointestinal tract is affected, not the genitourinary system. Gastroschisis involves the lower gastrointestinal system, so the oral mucous membranes are not affected.

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

Answer: 1 Nodding/smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of treatment, agreement with the speaker, or understanding the procedure.

The nurse determines that the client needs further instruction about prescribed thyroid replacement medication if which statement is made? 1."I should expect full therapeutic effect from the medication within 3 to 5 days." 2."I should take my medication in the morning about 1 hour before eating breakfast." 3."I need to make sure that I store the medication in the dark container I received it in." 4."I should check with my health care provider before taking any over-the-counter medications."

Answer: 1 The client should be taught that it may take up to 3 to 4 weeks to see the full therapeutic effects of thyroid medications, so expecting a full therapeutic effect in 3 to 5 days indicates a need for additional teaching. The medication should be taken in the morning to prevent insomnia at night and on an empty stomach. All thyroid tablets must be protected from light. The client taking thyroid medications should consult with the health care provider before taking any over-the-counter medications, and labels should be read thoroughly.