NCLEX Remediation: Quiz 1

The nurse is educating an older client on sources of stress. Which statements by the client indicate that the teaching has been effective? Select all that apply.

"Financial hardships can be a cause of stress." "A lifestyle change such as retiring can cause stress." "Relocating to a nursing home causes stress."

The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. Which statements by the RN indicate that teaching has been effective? Select all that apply.

"Healthy People 2020 aims to eliminate preventable disease, disability, injury, and preventable death." "Healthy People 2020 aims to create social and physical environments that promote good health for all." "Healthy People 2020 aims to promote healthy behaviors."

The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply.

"I feel like giving up." "My husband never helps me with the baby." "My baby will not stop crying and I can't take it anymore."

The nurse is caring for a client in the hospital and is reconciling the client's home medications. The client is taking Lactobacillus, a probiotic over-the counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply.

"I should take this supplement to prevent gas and bloating." "Because I'm lactose intolerant, a probiotic would not benefit me." "I can take my probiotic at any time of day or night."

The nurse is educating a client on how to prevent altitude sickness. Which statements indicate that the teaching has been effective? Select all that apply.

"I will refrain from consuming alcohol when I am at a high altitude." "I will drink plenty of water." "I will wear sunscreen and high quality goggles." "I will pay attention to the manifestations of altitude-related illnesses."

The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply.

A child with generalized anxiety disorder A child with autism

Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply.

Ascites Hepatomegaly Neck vein distention Dependent edema

The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action?

Check for a pulse Rationale: Ventricular tachycardia can be stable or unstable depending on whether the client has a pulse or not. In this case, assessing the client's pulse is the initial action. Obtaining a 12 lead ECG and notifying the health care provider may be necessary but are not initial actions. Initiating CPR may be necessary of the ventricular tachycardia becomes unstable and cardiac arrest occurs. Test-Taking Strategy: Note eh strategic word, initial. Use the steps of the nursing process and recall that assessment is the first step and the first action to take. Review: Ventricular Tachycardia

The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply.

Keep the client's door closed Wear a lead apron while providing care

The client has been diagnosed with valvular disease. Which interventions should the nurse be prepared to discuss with the client? Select all that apply.

Surgical management Medication management Placing limits on physical activity Monitoring for an irregular heart rhythm

The nurse is completing a health history on a client who is 12 weeks pregnant. Which findings should alert the nurse to the risk of potential parenting problems? Select all that apply.

The client reports feeling depressed The client states that the father is not supportive The client is homeless and often stays in local shelters

The nurse is caring for a client with bipolar disorder. When creating a care plan for this individual, which should the nurse include? Select all that apply.

The client will perform activities of daily living (ADLs) independently. The client will understand what bipolar disorder is. The client will state the importance of taking medications as prescribed. The client will be able to manage the symptoms of bipolar disorder.

A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply.

"Avoiding pain medication will prevent constipation." "I should drink plenty of liquids like iced tea or coffee." "Limiting fiber is necessary to avoid diarrhea."

The nurse is providing discharge teaching to the client who had a thoracentesis about the manifestations of a pneumothorax. Which statements should the nurse make to the client to help the client recognize signs/symptoms of a pneumothorax? Select all that apply.

"Be sure and report any bluish color to the skin." "Frequent coughing should be reported." "Presents of a slanted trachea in the neck region need to be reported." "A pneumothorax can cause a feeling of air hunger."

The nurse is attending a teaching sessionatt on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply.

"Complete honesty may cause problems for some family and staff members". "Children are often reluctant to ask questions, when they fear the answers". "To prevent misunderstandings, I should ask the child to explain what is known". "I will strive to maintain honesty and trust with each child".

The nurse is educating a child's parents on using the behavior modification technique of discipline. Which statement should the nurse make to the parents?

"Corporal punishment should not be used to encourage good behaviors." Rationale: The behavior modification technique of discipline rewards positive behavior and ignores negative behavior. This technique requires parents to choose selected behaviors, preferably only one at a time, that they desire to stop. They choose others that they want to encourage. The basic technique is useful for any age from toddlerhood through adolescence. Corporal punishment can lead to child abuse if the disciplinarian loses control. It can also lead to false accusation of child abuse by either the child or other adults. Because of the high cost and low benefit of this form of punishment, parents should avoid its use. When educating the paents, the nurse should provide accurate information such as: ignoring negative behaviors, giving rewards throughout and at the end of the training period and recording negative behaviors out of the client's view. Test-Taking Strategy: Focus on the subject, statement the nurse should make about behavior modification. Think about the components of behavior modification technique and read each option carefully to assist in answering correctly. Also note the closed-ended words "all" in option 1 and "only" in option 2. Review: Behavior modification

The nurse is educating a client on how to self-manage care at home, following an admission to the hospital for heart failure. Which statements by the client indicate that teaching has been effective? Select all that apply.

"I have my medications and dosages written down for easy review and administration." "I will weight myself daily." "I will wear my oxygen at night as prescribed." "I will follow up with my health care provider (HCP) as scheduled."

The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. What statements made by the client would indicate a need for further teaching? Select all that apply.

"I should avoid eating grapefruit while taking this medication." "To prevent a stomach ache, I should take this medication with food." "I should not take this medication more often than 3 times per day."

The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply.

"I tripped over a rug and now I have a black eye." "Sometimes my grandson becomes angry with me when I can't give him money." "Perhaps I somehow did this to myself." "Well, I don't remember anything that would have caused the injuries." Rationale: There are certain elements in the medical history that raise concern for physical abuse. Perpetrators may provide a history of events that are incomplete or inconsistent with injuries seen. Many individuals who experience interpersonal violence are unable or afraid to provide an accurate account of events. Often individuals will provide a history of trauma that is inconsistent with the physical examination. It is unlikely that these injuries were self-inflicted or the result of tripping over a rug. Having no recollection of how an injury occurred should be an alert to the nurse, as well as statements that another person caused the injury. The nurse should immediately report this to a health care provider and the social worker so that proper intervention and follow-up can be arranged. A car accident with air bag deployment could reasonably cause the injuries to the client. The nurse should continue on with assessment, treatment and arrange follow-up care for the client. Test-Taking Strategy: Focus on the subject, "abuse to an older client". Determine which statements made by the client would indicate that abuse may be occurring. Abuse individuals often make statements that do not correlate with injuries. Eliminate option 3, because air bag deployment could have caused the client's injuries. Review: Signs of abuse in the older client.

The nurse is providing discharge education to a client that was admitted for treatment with Addison's crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply.

"If I notice any swelling or fluid retention, I should notify my healthcare provider." " I should take this medication twice a day." Rationale: Hydrocortisone is used in the treatment of Addison's disease. Adverse effects such as weight gain, moon face, and fluid retention are not expected and may indicate over-correction and a dose adjustment is needed. This medication can be taken once or twice daily, and should not be doubled if a dose is missed. Test-Taking Strategy: Focus on the strategic word 'effective' to select correct statements made by the client. Think about the pathophysiology associated with Addison's disease and the effects of hydrocortisone on the disorder. This will assist in answering correctly. Review: Treatment for Addison's disease

The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply.

"Leflunomide is a potent medication that is generally tolerated." "Diarrhea is a common side effect." "It has been shown that leflunomide can cause birth defects." "You may lose your hair."

The nurse is educating a client on obesity. Which statements by the client indicate a need for further teaching? Select all that apply.

"My heart and lungs are mildly affected by obesity". "It is unlikely that I will develop peripheral artery disease". Rationale: Obesity refers to an excess amount of body fat when compared with lean body mass. After receiving education from the nurse, the client should be able to state that complications and risks of obesity such as type II diabetes and peripheral artery disease and other cardiovascular and respiratory system complications such as obstructive sleep apnea. It is also important that the nurse discuss the causes of obesity, which include physical inactivity. Encouraging the client to exercise 20 minutes per day can decrease the risk of obesity and life threatening illnesses. Test-Taking Strategy: Focus on the strategic words, "need for further teaching." Think about the physiological effects of obesity to assist in answering correctly. Eliminate statements that show that the teaching has been effective.

The nurse educator is presenting a lecture on child neglect. Which statement by one of the students indicates that the teaching has been effective? Select all that apply.

"Neglected children often have learning problems and low self-esteem." "Neglect is parental failure to meet a child's basic needs." "A sign of neglect are bruises on the child's body." "Neglect occurs when a parent does not seek medical attention for a sick child."

The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply.

"PICCs can accommodate infusions of all types of therapy." "The tip of the PICC line sits in the superior vena cava." "PICCs with a lumen size of 14 Fr or larger can be used for blood sampling." Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubitcal fossa (inner aspect of the bend of the arm) or the middle of the upper arm. When educating the new nurse on the purpose and use of PICC lines, the nurse preceptor should discuss the placement of the PICC line, including where the PICC line is placed in the body. The nurse should explain that PICC line insertions are typically done at the client's bedside, by a nurse with specialized training. PICC lines can accommodate infusions of all types of therapy because the tip sits in the superior vena cava, where the rapid blood flow quickly dilutes the infusion. The nurse preceptor should include information about blood sampling, such as only sampling blood from a PICC line with a lumen size of a 14 Fr or larger. The new nurse should also recognize that PICC lines are often used for client's who require long-term antibiotics, in order to protect the vein and skin tissue. Test-Taking Strategy: Focus on the subject, "an understanding about a PICC line." It is necessary to know about these types of infusion catheters in order to answer correctly. Thinking about the anatomical location of the tip of the catheter may assist in answering correctly. Review: PICC lines.

The nurse provides information to a unlicensed assistive personnel (UAP) about caring for a client with neutropenia. Which statements by the UAP indicate that teaching has been effective? Select all that apply.

"The client needs mouth care at least every 12 hours." "I should practice good hand washing." "The client may not have a high fever if infection occurs." "Any sores or skin irritations should be reported right away."

A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). The client will be discharged home on oral anticoagulants. What information in the client's medical record would warrant the need for teaching? Refer to chart. History and Physical • Iron-deficient anemia • 10 pack year history of smoking Laboratory Findings • Sodium 142 mEq/L (142 mmol/L) • Positive D-Dimer Medications • Lisinopril 10 mg orally daily • Vitamin D 400 IU daily

10 pack year history of smoking Rationale: A deep vein thrombosis (DVT) is the most common type of venous thromboembolism (VTE). DVTs occur most often in the legs, but can also occur in the upper arms. Smoking increases the risk of DVT formation, and clients should educated on the importance of quitting. The sodium result is within normal limits. The positive d-dimer result is expected, as it is a marker for DVT's. Vitamin D supplementation does not impact DVTs or anticoagulation therapy. Test Taking Strategy: Focus on the subject, deep vein thrombosis and anti-coagulation therapy. Note the strategic words "need for teaching." Think about the pathophysiology associated with DVT and the risk factors. Recall the implications of a DVT and treatment considerations to correctly answer this question. Review: Deep Vein Thrombosis

The nurse is caring for a client with a blood pressure of 80/54 mmHg. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply.

Anticipate administering blood products Perform assessments and monitor the client closely Anticipate administering Ringer's lactate solution Insert a large-bore intravenous (IV) line Rationale: Hypovolemic shock occurs when there is a decrease in the circulating blood volume in the body. When treating a client in hypovolemic shock, the nurse should insert a large-bore IV line, administer Ringer's lactate or 0.9 % normal saline solutions, perform assessments and monitor the client closely, and anticipate administering blood products. These treatments will restore circulating blood volume to the client. Intravenous fluids should be warmed prior to administration to the client. Test-Taking Strategy: Focus on the subject, "treating hypovolemic shock." Recall the pathophysiology associated with hypovolemic shock to assist in answering correctly. Eliminate option 3, because intravenous fluids should be warmed prior to administration. Review: Hypovolemic shock.

The nurse is working in the emergency department when a client with heat exhaustion is brought in. Which actions would be the appropriate in order to effectively treat the client? Select all that apply.

Apply ice packs to the client's neck and groin. Remove any restrictive clothing. Give the client an oral rehydrating solution. Apply cool water soaks to the client.

The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply.

Assess lung sounds Obtain and monitor vital signs Measure urine output

The nurse is caring for a client who has been diagnosed with bladder cancer. Which action should the nurse take as a priority when planning psychosocial care for this client?

Assess the client's ability to cope with the diagnosis Rationale: Urothelial cancers are malignant tumors of the urothelium—the lining of transitional cells in the kidney, renal pelvis, ureters, urinary bladder, and urethra. Most urothelial cancers occur in the bladder. Thus the term bladder cancer is often used to describe this condition. The nurse should take time when planning care in order to ensure that client specific care is given. When planning care that includes the psychosocial needs, the priority action for the nurse should be to assess the client's ability to cope with the cancer diagnosis. Other important aspects of caring for this client are to assess the urine and determine the client's medical history, including family history of cancer but these are physiological aspects. Questioning the client's insurance coverage is not typically a nursing function. Test-Taking Strategy: Focus on the strategic word, "priority" and the subject, psychosocial care. Determine which action would help maintain the client's psychosocial integrity. Eliminate options 1, 2, and 4, because while these actions fulfill other client and hospital needs, they do not specifically meet the client's psychosocial needs. Review: bladder cancer and psychosocial needs.

The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply.

Assess the client's eyesight. Assess the client for mental status changes. Determine the fit of the client's dentures. Obtain a list of the client's medications. Rationale: Older adults in the community or in any health care setting are most at risk for poor nutrition. The nurse should review the medical history to determine the possibility of increased metabolic needs or nutritional losses, chronic disease, trauma, recent surgery of the gastrointestinal tract, drug and alcohol abuse, and recent significant weight loss. Each of these conditions can contribute to malnutrition. As part of a thorough assessment, the nurse should assess the client's eyesight. Clients with poor vision are often not able to drive to obtain groceries or cook for themselves. The nurse should also obtain a list of the client's medications, both prescription and over-the-counter. Certain medications can alter the taste perception and decrease the desire to eat. It is also important for the nurse to determine the fit of the client's dentures. Poor fitting dentures can lead to painful sores, which lead to a decrease in food intake. The nurse should also include an assessment of the client's mental status, observing for behavoir that may be abnormal for the client. Utilizing the family member's knowledge of the client's typical behavior will be important in the treatment of this client. While the client's urinary status is important to assess, it is not the most important action for the nurse to take at this time because it is not directly related to weight loss. Test-Taking Strategy: Focus on the strategic words, "most important". Next, determine which actions would help the nurse determine the cause of the client's weight loss. Eliminate option 2, because questioning the client's urinary habits would not be directly related to determining the cause of weight loss. Review: Older Adult Nutrition.

The nurse is caring for a client who has just come in to the emergency department to receive treatment. The client reports a bite from a brown recluse spider. The nurse assesses the bite mark and notes that it is possibly infected. Which actions should the nurse take? Select all that apply.

Assess the date of the client's last tetanus shot. Apply ice to the site. Cleanse the area with a topical antiseptic.

Which interventions should be included in the care of a client with a chest tube? Select all that apply.

Assess the insertion site for signs of infection. Keep the drainage system lower than the level of the client's chest. Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours. Rationale: Caring for a client with a chest tube involves an adequate understanding of chest tubes and interventions needed to ensure sterility and patency. The chest tube site should be assessed for signs of infection and the drainage system should always be kept below the level of the client's chest to ensure adequate drainage. If drainage stops in the first 24 hours, the HCP should be notified immediately because there could be a blockage in the tube. The chest tube is not changed each shift and the system needs to remain closed and patent. A continuous strong bubbling in the water seal chamber indicates an air leak, requiring further investigation. Test-Taking Strategy: Focus on the subject, chest tube care. Think about the physiological functioning of a chest tube and the purpose of a chest tube to assist in answering correctly. Review: Chest tube care.

The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply.

Assess the skin integrity Educate the client about the signs and symptoms of infiltration Place the IV at an area of flexion Understand the vesicant potential before administering the infusion Monitor the site frequently Rationale: It is important that the nurse take time to prepare for the IV infusion before administering any medication. The nurse should assess the client's skin integrity prior to selecting an IV site. The nurse should avoid placing the IV at an area of flexion, such as in the antecubital space, or any other space that will limit or prevent the client's range of motion. The nurse should plan to monitor the site frequently for signs of infiltration. The nurse should also educate the client about the signs and symptoms of infiltration and inform the client to alert the if any signs such as discomfort occur. Prior to administering the infusion, the nurse should understand the vesicant potential. Test-Taking Strategy: Focus on the subject, "creating a plan of care for a client receiving an IV infusion of a vesicant medication." Remember that the nurse needs to know what is being administered before administration. Next remember that assessing and monitoring is always a part of a plan of care as is client education. Eliminate option 3 noting the words "area of flexion." Review: Skin Integrity.

The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply.

Assist the child's parents in obtaining the medication at an affordable cost. Create a medication schedule that fits the parent's lifestyle. Provide the child's parents with a simple dosing schedule. Ensure that the child's family is able to read the written discharge instructions. Rationale: Medicating infants and children is an important nursing responsibility. The nurse plays a key role in administering medications, supporting the child and family during the experience, and teaching the child and parents about pharmacologic aspects of the child's care. The nurse should not only coordinate the child's care, but also the discharge process. It is important that the nurse create a medication schedule that fits the family's lifestyle and provide the family with a simple dosing chart. This helps to ensure that the childreceives proper medication dosing and prevents medication errors. The nurse should consider cost of prescribed medications and providing the family with resources as needed. During the discharge process, the nurse should verify that the family can read the written discharge instructions and answer any questions about the prescribed medications, including side effects. Test-Taking Strategy: Focus on the subject, "discharge planning" and "medication instructions." The discharge process is often complex, the nurse should take actions to simplify this as much as possible. Eliminate options 5, because the nurse should review medications and side effects with the family during the discharge. Although the pharmacist is an excellent resource, it is the nurse's responsibility to teach about the medication. Review: Discharge teaching.

The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply.

Check the health care provider's prescriptions with another nurse. Assess laboratory values. Evaluate the client's venous access. Obtain and assess vital signs. Rationale: Preparation of the client for transfusion therapy is critical, and institutional blood product administration procedures must be carefully followed. Before administering any blood product, review the agency's policies and procedures. The nurse should take care to ensure that the client is adequately prepared to receive the blood. This is accomplished by assessing the client's laboratory values, in order to determine the client's need for intervention. The nurse should be aware of the health care facilities policies and procedures regarding blood administration. The nurse should also obtain and assess the client's vital signs, prior to blood administration. This is completed so that the nurse can detect any change from the client's baseline during the administration. The client's venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in place and patent. Checking the health care provider's prescription with another nurse is a crucial step that must be completed. The nurse should not simply identify the client by room number and bed. The nurse must follow the policies and procedures set by the health care facility for safe blood administration. Test-Taking Strategy: Focus on the strategic words, "most appropriate." Determine which actions should be completed by the nurse prior to blood administration. Eliminate option 4, because this step is unsafe and could lead to client harm. The nurse should identify the client using appropriate and safe identifier guidelines. The nurse should take steps to provide for client safety during blood administration. Review: Blood Administration.

A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply.

Chronic illness Environmental exposure to toxins Income Low birth weight

The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first?

Clarify the medication prescription with the health care provider. Rationale: After fracture treatment, the client often has pain for a prolonged time during the healing process. The health care provider commonly prescribes opioid and non-opioid analgesics, anti-inflammatory drugs, and muscle relaxants. The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can cause seizures and other complications. The first step the nurse should take is to clarify the prescription with the health care provider. The other steps should not be done. Test-Taking Strategy: Focus on the strategic word, "first" and focus on the data in the question and that the client is an older client. Determine which step the nurse should take first when receiving the medication order. Eliminate options, 1, 2, and 3, because this medication should not be given to an older client. Review: contraindications for meperidine

The nurse is caring for a client on a ventilator. Which symptoms should alert the nurse to the possibility of absorption atelectasis? Select all that apply.

Crackles in the lungs Diminished lung sounds Rationale: Nitrogen in the air helps maintain patent airways and alveoli. Making up 79% of room air, nitrogen prevents alveolar collapse because it does not cross the alveolar-capillary membranes and remains in the airways and alveoli. When high oxygen levels are delivered, nitrogen is diluted, oxygen diffuses from the alveoli into the circulation, and the alveoli collapse. Collapsed alveoli cause atelectasis (called absorption atelectasis), which is detected by auscultation. The nurse providing care to the ventilated client should be alert for signs of absorption atelectasis. These symptoms include: crackles in the lungs and diminished lung sounds. The nurse should intervene when these symptoms are present. High oxygen saturation, decreased blood pressure, and an increase in the red blood cell count are not typical signs of absorption atelectasis. Test-Taking Strategy: Focus on the subject, "the symptoms of absorption atelectasis." It is necessary to understand the pathophysiology associated with this condition to answer correctly. Think about the pathophysiology and what occurs in the lungs as a result of this condition. This will assist in selecting the correct options. Review: symptoms of absorption atelectasis

The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply.

Cyanosis of the skin in the affected extremity Skin temperature cool to touch in the affected extremity Complaints of sudden and severe pain in the affected extremity Client complaints of problems moving the affected extremity

The nurse is caring for an older client who is being treated for malnutrition. Which actions by the nurse would be the most appropriate when providing for this client's care and comfort? Select all that apply.

Determine if the client qualifies for any food services. Ask if the client lives alone. Educate the client on how to choose healthy foods. Evaluate the fit of the client's dentures. Rationale: The minimum nutritional requirements of the human body remain consistent from youth through old age, with a few exceptions. Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A because aging changes disrupt the ability to store, use, and absorb these substances. A sedentary lifestyle and reduced metabolic rate require a reduction in total caloric intake to maintain an ideal body weight. Malnutrition or nutrition-related problems can occur in older adults when these needs are not met. When caring for the malnourished client, the nurse should evaluate the client's living situation. Older clients, who live alone, are more likely to become malnourished. The nurse should also evaluate the fit and comfort of dentures. The client is less likely to eat if dentures are poor fitting. It should not be assumed that the client understand what foods are considered healthy and which are not. The nurse should be prepared to determine the client's level of knowledge and educate as necessary. Food services, such as meals on wheels, provide food to the older client who may not be able to obtain food on their own. The nurse should assess the client to determine if this assistance would be an option. Over-the-counter medications can cause changes in taste, placing the client at a greater risk for a decreased appetite. The client should speak with the health-care provider before beginning any over-the-counter medication. Test-Taking Strategy: Focus on the strategic words, "most appropriate." Note the subject, the actions by the nurse that would assist in providing for the client's care and comfort. Eliminate option 5, because this action could potentially place the client at a greater risk for malnutrition. Review: Malnutrition in the older client.

The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply.

Eat a healthy, well-balanced diet Exercise on a regular schedule Don't overcommit yourself to activities that will be tiring Try to sleep when the baby sleeps Rationale: The postpartum nurse must observe the new mother carefully for any signs of tearfulness and conduct further assessments as necessary. Nurses must discuss post-partum depression to prepare new parents for potential problems in the postpartum period. The nurse can provide activities and recommendations to improve the client's health and well-bring. Exercising on a regular basis will help the client feel better and maintain physical health, as well as eating a healthy diet. The nurse should also suggest avoiding over commitment to activities that will tire the new mother. The nurse should advise the client to sleep when the infant sleeps. While it is important for the client to bond with the infant, the client should not be isolated from friends and family. Test-Taking Strategy: Focus on the strategic words, "most appropriate." Determine which activities will assist the client in preventing post-partum depression. Eliminate option 5 because it isolates the client from others and could lead to post-partum depression. Review: Prevention of post-partum depression.

The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. What priority actions should the nurse include in the plan of care? Select all that apply.

Encourage use of an abdominal pillow when coughing or deep breathing Administer analgesics as needed Assess for pedal pulses Monitor urinary output Rationale: A priority nursing action after an AAA repair with a graft is to ensure patency of the graft. In order to do this, the nurse would monitor vital signs, pedal pulses, urinary output, and extremity color at least hourly. Pain medication is administered as needed and as prescribed and administered regularly for better pain management. The head of the bed is maintained at 45 degrees or less to prevent flexion of the graft. The client should be instructed to use an abdominal pillow when coughing or deep breathing to prevent incision splitting. Test-Taking Strategy: Focus on the strategic word 'priority' to select correct options to be included in the care plan. Focus on the data in the question and the surgical procedure. Not that the client had a graft stent and think about the impact of vascular patency to answer correctly. Review: care following an Abdominal Aortic Aneurysm with graft

A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply.

Ensure the client is an active part of decision making regarding their care. Encourage friends and family to visit frequently. Establish a trusting relationship with the client as soon as possible. Rationale: Relocation stress can occur when a client is removed from their usual surrounding such as home. In order to provide safe and quality care, encourage friends and family to visit the client often and establish a trusting relationship with the client as soon as possible. It is important for the client to have an active role in decision-making. In order to lessen confusion, the nurse should provide the client time to become familiar with the immediate surroundings such as his or her room before allowing or encouraging ambulation to new surroundings; allowing the client to move around the halls as desired may increase confusion and acting-out behaviors. Likewise, changing the client's room frequently may increase confusion. Test-Taking Strategy: Focus on the subject, relocation stress. Also note that the client is confused and acting-out. Think about this type of stress and the manifestations and what you might expect from a client who is experiencing relocation stress. Use that knowledge to determine appropriate nursing actions. Review: relocation stress.

The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart. Medical History • Asthma • Diabetes mellitus Assessment Findings • Hoarse voice • Blood pressure 98/62 mmHg Laboratory Values • Sodium 131 mEq/L (131 mmol/L) • Blood glucose 68 mg/dL (3.7 mmol/L)

Hoarse voice Rationale: Clients with major burns are at risk for respiratory compromise. A hoarse voice is an impending sign that the client may soon lose his airway due to obstruction or swelling. This would indicate the need to immediately activate the rapid response team as intubation is required. A history of asthma may impact respiratory status, however, the presence of asthma alone does not warrant a call to the rapid response team. The client's blood glucose reading is low, and should be treated, however, this can be done by the RN assigned to the client and does not warrant a rapid response team. Hypovolemia is associated with burns and would explain the low blood pressure reading. Test-Taking Strategy: Note the strategic word 'immediately'. Use the ABC - airway, breathing, and circulation to assess airway first. In this case, a hoarse voice would indicate a problem with the airway. Review: Burn care

The nurse notices that an older client's skin is very dry. What actions would be appropriate for the nurse to implement into the care plan? Select all that apply.

Instruct the client to avoid caffeine and alcohol Ensure adequate hydration Rationale: The skin functions to protect the body. In order to promote good skin health, hydration is important. Ensuring adequate hydration can help hydrate the skin from the inside out. Dehydration is avoided by eliminating substances such as caffeine and alcohol. Lotion can be beneficial if applied 2 to 3 minutes after bathing when skin still has moisture. Rubbing the skin can further dry the skin. Scented soaps, lotions, and oils can dry out the skin. Test-Taking Strategy: Focus on the subject of the question, actions to prevent and treat dry skin. Read each option and think about how it may or may not further dry the skin. Review: measures to prevent and treat dry skin

The nurse is providing care to a client. After assessing the client, the nurse determines that the client's self ability to change position is compromised. Which actions should the nurse take to reduce the risk of skin break down? Select all that apply.

Keep the client's skin clean and dry Decrease the risk for skin shearing Implement a turning schedule Document skin breakdown prevention measures in the plan of care

A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply.

Making statements about being fat and unattractive now. Not responding to the infant's cries. Stating that family was not supportive of the pregnancy. Crying after talking with spouse on the phone. Rationale: The weeks following the birth are a time of vulnerability to psychiatric disorders, such as depression for many women, causing significant distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social development. Mood and anxiety disorders are particularly likely to recur or worsen during these weeks. Such conditions can interfere with attachment to the newborn and family integration, and some may threaten the safety and well-being of the mother, the newborn, and other children. It is important that the nurse frequently assess the client for post-partum depression. Ignoring the infant's cries should alert the nurse that further assessment is needed. Crying after talking with a spouse of the phone could indicate a problem at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety and well-being of the client and infant. The nurse should also address the client's statements about body image, educating the client about what is normal and what is not normal in the post-partum period. Stating that the infant latched on during a feeding is a positive action and would not indicate the need for further assessment. Test-Taking Strategy: Focus on the strategic words, "need for follow-up." Determine which actions by the client indicate that the client could be experiencing post-partum depression. Eliminate option 5, because this statement is positive and does not indicate that the client is experiencing post-partum depression. Review: Post-partum depression.

The nurse is caring for a client with heat stroke, who is being cooled with a cooling blanket. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply.

Monitor temperature continuously until it is stable Rapidly lower the core temperature Prepare to insert an intravenous line for administration of fluids as needed Monitor for patency of the airway and prepare for intubation if necessary Rationale: Victims of heat stroke have a profoundly elevated body temperature (above 104 °F [40°C]) and need to be treated immediately with cooling measures to rapidly lower the body temperature. The nurse would monitor the temperature continuously using a rectal thermometer or other acceptable temperature measuring method. An intravenous line is inserted to administer fluids such as 5% dextrose in the event of hypoglycemia that can occur as a complication. The nurse should not administer antipyretics. Antipyretics can interrupt the change in the hypothalamic set point and are not expected to work on a healthy hypothalamus that has been overloaded, as in the case of heatstroke. In addition, they can be harmful in some situations. Test-Taking Strategy: Focus on the subject, "treating a client with heat stroke." It is necessary to understand the pathophysiology associated with heat stroke to answer correctly. Remember that antipyretics are not a part of the treatment plan for a client with heat stroke. Review: management of heat stroke

The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump. When creating the client's plan of care, which opiate-induced side effects should the nurse monitor? Select all that apply.

Nausea and vomiting Sedation Rationale: Patient-controlled analgesia (PCA) is a common way to address the problem of inadequate analgesia by allowing the client to control the dosage of opioid received. This approach to pain control can improve pain relief and increase client satisfaction. It can also decrease the amount of opioid consumption per day when compared with nurse-administered intermittent dosing methods. When creating the plan of care, the nurse should anticipate opiate-induced side effects, and be prepared to monitor for them and manage them. These side effects include sedation, nausea, and vomiting. High blood glucose, increased appetite and elevated cardiac enzymes are not typical opiate-induced side effects. Test-Taking Strategy: Focus on the subject, "opiate-induced side effects." Think about the physiological effects of an opiate on the body to assist in answering correctly. Review: Opiate-induced side effects.

The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis, and is creating a plan of care for the client's nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply.

Play soft, calming music during mealtimes. Provide pain medications as needed. Provide the client with six small meals per day. Serve the food at the appropriate temperature. Rationale: Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to poverty, lack of education, substance abuse, decreased appetite, and a decline in functional ability to eat independently, particularly in older adults. In order to support the client, the nurse should provide pain medication as needed so that the client is comfortable during meal times. The nurse can make mealtime positive by providing a quiet environment, which is conducive to eating. Soft music may calm those with advanced dementia or delirium. It is important that the nurse serve the client's food at the appropriate temperature, in order to make the food appealing to the client. Arranging for the client to eat six small meals per day, instead of three large meals, may increase the client's desire to eat, and prevent the client from being overwhelmed by a large amount of food at each meal. It is important that the nurse avoid rushing the client through a meal, but allow as much time as needed. Test-Taking Strategy: Focus on the strategic words, "most appropriate." Eliminate option 5, because this action would likely cause the client to take in fewer calories. Review: Malnutrition.

The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. History and Physical: • Expiratory rales on auscultation • Peripheral Vascular Disease (PVD) Laboratory Findings: • Blood pressure 145/94 mmHg • Serum Potassium 3.5 mEq/L (3.5 mmol/L) Medications: • Lisinopril 20mg orally daily • Atorvastatin 10mg orally at bedtime

Potassium level of 3.5 mEq/L (3.5 mmol/L) Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by the administration of furosemide. Test-Taking Strategy: Focus on the subject, the need to verify continuing the prescription. Note the data in the question and that the client is receiving furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the side and adverse effects of this medication to answer correctly. Review: furosemide

The nurse is preparing to administer oral potassium chloride to a client. What should the nurse keep in mind about this medication? Select all that apply.

Potassium may be taken in a liquid or solid form. Potassium chloride can cause nausea and vomiting. Potassium has a strong, unpleasant taste. Rationale: Interventions for hypokalemia aim to determine the cause, prevent further potassium loss, increase serum potassium levels, and ensure client safety. When preparing to administer potassium to the client, the nurse should keep in mind that potassium has a strong, unpleasant taste that is often difficult to mask. The client should be made aware of this beforehand. Oral potassium may be taken as either a liquid or a solid. This is important to keep in mind for clients who have difficulty swallowing large pills. The nurse should be aware that potassium chloride can cause nausea and vomiting, therefore it is recommended that the client take the medication with food. Potassium can be mixed with a variety of liquids, in order to make the medication more pleasant for the client. Potassium should never be administered IM, because it is a severe tissue irritant. Test-Taking Strategy: Focus on the information in the question, "administration of oral potassium." Eliminate option 2 because of the closed-ended word "only." Noting that the question is asking about oral administration will assist in eliminating option 5. Review: Potassium chloride

The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply.

Provide culturally sensitive education. Encourage family members to obtain a tuberculosis skin test. Urge all family and close contact community members to seek and complete treatment to enhance compliance. Rationale: As always, the nurse must provide culturally sensitive education. Because tuberculosis is highly contagious, all family members and close community members should have a tuberculosis skin test, seek treatment, and remain compliant. A full course of 6-9 months of treatment is needed to prevent re-infection. Instructions written in English are not helpful for the client with limited English skills. Washing dishes by hand is not the best way to prevent infection; rather a dishwasher should be used if available. Test Taking Strategy: Focus on the strategic word most to select correct options that relate to appropriate teaching for both the client and family members. Also, focusing on the data in the question will assist in answering. Review: Tuberculosis

A client has come to the emergency department complaining of burning with urination. What should the nurse consider a priority when providing care in order to maintain the client's psychosocial integrity?

Provide the client with as much privacy as possible during the examination. Rationale: Infections of the urinary tract and kidneys are common, especially among women. In caring for the client, the nurse should consider ways in which to maintain psychosocial integrity. Providing the client with as much privacy as possible during the examination is the best way to achieve this, and should be considered a priority by the nurse. Using medical terminology may be confusing to the client. The nurse should explain all actions and procedures to the client before they occur. Administering medications as soon as prescribed is important, but does not necessarily maintain the client's psychosocial integrity in this situation. Test-Taking Strategy: Focus on the strategic word, "priority" and the subject, maintaining the client's psychosocial integrity. Noting the word, privacy, in option 2 will direct you to this option. . Review: measures to maintain a client's psychosocial integrity.

When conducting the preoperative interview with the client, the client reports an allergy to shellfish. Which agent is most likely to cause an allergic reaction in this client?

Providone-Iodine Rationale: The client's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the client for the surgery and client safety. Preoperative interviews are conducted in order to gather client information before the surgery. This allows time for interventions and special considerations to be made. The nurse should anticipate this client to have an allergic reaction to providone-iodine, also known as betadine. It is important that the nurse report the allergy to shellfish to the surgeon right away so that another method of skin cleansing can be chosen. Latex, IV fluids, and medical-tape are not considered cross allergens for shellfish. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, "a client with a shellfish allergy." Determine what could cause an allergic reaction in the client. Eliminate options 1, 2, and 4 because these options are not shown to cause reactions in a client with a shellfish allergy. Also think about the association between shellfish and iodine. Review: Allergy to shellfish

The nurse is caring for a client with a latex allergy. Upon entering the client's room, the nurse should plan to take which action as the priority?

Remove the banana from the client's breakfast tray Rationale: A sensitivity or allergy to certain substances alerts the nurse to other possible cross allergies. The nurse should be aware of this and prevent allergic reactions whenever possible. The nurse should know that the client with an allergy to latex, may also be allergic to bananas. The priority action that the nurse should plan to take when entering the client's room, is to remove the banana from the client's breakfast tray. The other actions can be completed once the risk of allergic reaction has been removed. Test-Taking Strategy: Focus on the strategic word, "first" and focus on the data in the question, that the client has a latex allergy. It is necessary to know cross-sensitivities to answer correctly. Eliminate options 1, 2, and 3, because these actions can safely wait until the banana has been removed from the client's breakfast tray. Also note that options 1 and 2 are comparable or alike and can be eliminated. Review: latex allergy

The nurse is caring for an older Japanese American man being treated in the oncology unit for prostate cancer. In order to provide culturally competent care, the nurse should include what actions in the care plan? Select all that apply.

Routinely assess for pain, as Japanese Americans often remain stoic Provide personal space boundaries if client is in a semi-private room Allow for family to visit and participate in the decision-making process Rationale: The client of Japanese descent often remains quiet and stoic, and therefore may not voice pain and should be assessed frequently. The nurse should pay attention to non-verbal signs of pain. Providing personal space boundaries may help alleviate tension and allowing family to partake in decision-making is an integral part of providing culturally competent care. Some Japanese American clients may be offended if called by their first name, and may not wish to talk frequently. Test-Taking Strategy: Focus on the subject of the question, culturally competent care for the Japanese American client. It is necessary to understand the common characteristics of this culture in order to answer correctly. Review: Culturally competent care for Japanese American

The nurse is caring for a client in active labor. The nurse notices that the fetal heart rate pattern is demonstrating late decelerations. Which position should the nurse assist the client into? Refer to figures.

Side lying position Rationale: Late decelerations are a nonreassuring fetal heart rate that implies a decrease in placental sufficiency. To promote adequate oxygenation and blood flow to the fetus, the client should be assisted to a side lying position. Re-positioning may improve perfusion and the fetal heart rate. Positions such as prone and dorsal recumbent should be avoided to prevent compression of the vena cava and decreased blood flow. Knee-chest position may improve comfort, but side lying is best for perfusion. Test Taking Strategy: Focus on the subject, maternal positioning for late decelerations. Recall that late decelerations imply placental insufficiency, so assist the client to a position that will promote blood flow to the placenta. Review: Labor positioning.

The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client's plan of care? Select all that apply.

Teach interventions to reduce client anxiety Complete a physical assessment before the surgery Include the client's family in discussions about the surgery Educate the client on what to expect after surgery

The client with heart failure is preparing to be discharged from the hospital. Which interventions should the nurse include in the client's discharge teaching plan? Select all that apply.

Teach the client coping strategies Educate the client about dietary restrictions Develop a regular exercise program Provide the client with a list of current medications and dosing times

Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply.

Tell the client to expect a stinging sensation from the anesthetic Explain the procedure to the client Inform the client that it is common to feel pressure from the needle insertion Instruct the client not to move during the procedure Rationale: Thoracentesis is the aspiration of pleural fluid or air from the pleural space. It can be used for diagnosis or treatment. In preparing the client for a thoracentesis, the nurse should thoroughly explain the procedure to the client, allowing time for the client to ask questions. The nurse should also instruct the client not to move during the procedure, and therefore the client should not cough or take deep breaths, in order to avoid puncture of the lungs or pleura. The client should be informed to expect a stinging sensation and pressure as the needle is inserted. Test-Taking Strategy: Focus on the subject, "preparing a client for a thoracentesis." Think about the purpose of the procedure and how it is done by the health care provider. Eliminate option 3, because the client should be instructed not to move during the procedure and therefore needs to avoid taking deep breaths during the thoracentesis. Review: thoracentesis.

The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply.

The length of time for the administration The route and frequency of administration The specific dosage The generic medication name Rationale: Medication safety is extremely important in all health care settings. The Joint Commission publishes new and updated National Patient Safety Goals (NPSGs) every year. The nurse should be prepared to evaluate each medication prescription to ensure that the proper information is included, and intervene when necessary to provide safe client care. The information should include: the specific dosage, generic drug name, length of drug administration and route and frequency of administration. The medication prescription does not need to include the client's home address. Test-Taking Strategy: Focus on the subject, "verifying the required information in a medication prescription." Determine what information is pertinent for safety. Eliminate option 2, because the client's home address is not considered pertinent information in this situation. Review: Components of a medication prescriptions

The nurse is planning care for a client who is confused. The nurse should include which actions in the client's care plan? Select all that apply.

Toilet the client every 2 to 3 hours Allow a pet visit Play soft, calming music Evaluate the client for signs of pain Rationale: Acute and chronic confusion affect many older clients in both the hospital and nursing home. Whereas chronic confusion states such as dementia are not reversible, acute confusion or delirium may be avoidable and is often reversible when the cause is resolved or removed. The nurse should plan care that keeps the client as comfortable and peaceful as possible. If possible, the nurse should allow a pet visit. The nurse should also ensure a comforting environment. Many times clients who are confused are unable to express the need to be toileted, which can increase agitation. It is also important that the nurse evaluate the client for pain, and treat the pain immediately. Applying restraints should be a last option. Restraints often increase agitation and lead to the client becoming violent. Test-Taking: Focus on the subject, "care for a client who is confused." Determine which actions the nurse should take to provide the best care to this client. Eliminate option 5, because this action could lead to increased agitation or violence. Review: Confusion.

The nurse is creating a plan of care for a client with a respiratory infection. Which actions should the nurse include in the plan of care to prevent the spread of infection? Select all that apply.

Wear gloves when giving a bath to the client Place a mask on the client's face when transporting to other departments Keep fingernails short and without nail polish Clean the client's room daily Rationale: Infection control within a health care facility is designed to reduce the risk for health-care associated infections (HAI). The nurse must implement measures to prevent the spread of infection. The nurse should include the following in a plan of care for the client: daily room cleaning to remove infectious material; using personal protective equipment, such as gloves, when giving the client a bath to prevent the spread of infection; keeping fingernails short and without nail polish because of the risk of harboring bacteria; and use of a mask when the client is transported to other departments to prevent spread. In addition, other departments that the client is being transported to should be aware of the risk of respiratory infection. The nurse should wash hands after every client contact or more frequently if needed, not just when they are soiled. Often hands may not look soiled, but can have infectious material on them. Review: health-care associated infection prevention. Test-Taking Strategy: Focus on the subject, "preventing the spread of a respiratory infection." Determine which actions by the nurse prevent infection from being spread. Eliminate option 2, because hands should be washed after each client contact not just when soiled. Review: measures to prevent the spread of infection

The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all that apply.

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