NCSBN Practice Questions 16-30

The nurse is teaching a 10 year-old child prior to heart surgery. Which form of explanation meets the developmental needs of this age child? A. Explain the surgery using a model of the heart B. Introduce the child to another child who had heart surgery three days ago C. Provide the child with a booklet to read about the surgery D. Provide a verbal explanation just prior to the surgery

A According to Piaget, the school-age child is in the concrete operations stage of cognitive development. The use of something concrete, like a model will help the child understand the explanation of the heart surgery.

A client with a panic disorder has a new prescription for alprazaolam. In teaching the client about the drug's actions and side effects, which point should the nurse emphasize? A. Short-term relief can be expected B. Dosage will be increased as tolerated C. The medication acts as a stimulant D. Initial side effects often continue unchanged

A Alprazaolam (Niravam, Xanax) is a short-acting benzodiazepine useful to quickly control panic symptoms.

A client has been taking alprazolam for three days. The nurse should expect to find which intended effect of this drug? A. Tranquilization and calming effects B. Increased coordination and ability to concentrate C. Relief of insomnia and phobias D. Sedation and long-term analgesia

A Alprazolam (Xanax) is a benzodiazepine used in the treatment of anxiety, panic disorder, and anxiety associated with depression; it is also beneficial to those suffering from sleep disorders. This medication is a central nervous system depressant, producing a drowsy or calming effect; it may cause a lack of coordination. Alprazolam has a very short half-life and produces immediate symptom relief. It does not cause analgesia nor is it used to treat phobias.

An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight change at six months of age? A. Double the birth weight B. Triple the birth weight C. Gain six ounces each week D. Add two pounds each month

A Although growth rates vary, infants normally double their birth weight by six months. At 12 months weight is tripled.

The pregnant woman asks how a health care provider (HCP) can tell she is pregnant "just by looking inside." What is the best explanation for this? A. Bluish coloration of the cervix and vaginal walls B. Pronounced softening of the cervix C. Slight rotation of the uterus to the right D. Plug of very thick mucus

A Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls. It develops after the 6 to 8 weeks and is caused by increased blood supply to the area. Other early signs of pregnancy include Hegar's sign (a softening of the cervical isthmus) and Goodwell's sign (a softening of the cervix), but the HCP would need to compress the tissue to assess these findings. The HCP would not see the mucus plug; the mucus plug dislodges, breaks up and passes out of the body just prior to labor.

The nurse is caring for a 2 month-old infant with a congenital heart defect pre-operatively. How does the nurse best promote adequate nutrition while meeting the child's health needs? A. Support the mother who breastfeeds B. Supplement bottle feedings with water C. Mix medications with formula or breastmilk in a bottle D. Provide bottle feedings every 2 hours

A Children with congenital heart defects have increased nutritional needs and tend to tire quickly during feeding. Breastmilk offers optimal nutrition and the work of breast-feeding is less than the work of bottle-feeding, which is why the nurse should support the mother's efforts to breast-feed. Infants with congenital heart disease usually do better when fed more often and on a demand schedule; usually 8 to 12 times a day is fine. The infant should not be given water since there are no calories in water. Medications should never be mixed with milk or formula.

The client is being treated for tuberculosis (TB). Which assessment would indicate that the client is having a possible adverse response to isoniazid? A. Appearance of jaundice B. Decreased hearing C. Severe headache D. Tachycardia

A Clients who are being treated with isoniazid are at risk for developing drug-induced hepatitis. The appearance of jaundice may indicate an elevation of the client's serum bilirubin levels; liver enzymes (AST and ALT) will also be elevated. A small number of adults taking isoniazid develop severe hepatitis that may progress to liver failure and even death unless the drug is stopped immediately.

A staff nurse informs the charge nurse about an issue between two of the unlicensed assistive personnel (UAP) on the unit. What is the most important guideline for the nurses to remember when resolving this conflict between the UAPs? A. Deal with the issues, not personalities B. Explain the consequences of not resolving their differences C. Encourage the UAPs to ventilate their anger and use humor to minimize the conflict D. Require the UAPs to reach a compromise

A Dealing with the issues, and not the personalities, is one of the important key behaviors in managing conflict. Issues tend to be more concrete, whereas personalities involve emotional issues. When there is conflict, emotions run high and it would be best not to let the UAPs ventilate their anger. If necessary, potential consequences of not resolving any differences between the UAP would be discussed last.

The nurse receives report on the following client assignments. Which client should the nurse assess first? A. A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy B. A client who underwent a partial gastrectomy and reports feeling lightheaded C. A client diagnosed with gastroesophageal reflux disease (GERD) reporting difficulty swallowing D. A client reporting severe gastric distress after taking ibuprofen

A Dizziness with PUD may indicate hemorrhaging. The findings in the other options are either expected and are not life-threatening: clients may feel lightheaded when they are not drinking enough fluids after a gastrectomy; difficulty swallowing can be a symptom of GERD; gastrointestinal symptoms are the most common side effects of NSAIDs.

At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. The client asks about preconception diet changes. Which of these statements made by the nurse is the best approach in this situation? A. "Increase your intake of green leafy vegetables." B. "Eat at least one serving of fish weekly." C. "Drink a glass of milk with each meal." D. "Include fiber in your daily diet."

A Folic acid sources should be included in the diet and are critical in the preconceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida.

The client is admitted to the emergency department with hypertensive crisis. Which finding requires immediate action by the nurse? A. Weakness in left arm B. Jugular vein distension C. Crackles at the lung bases D. Lower extremity pitting edema

A In a client who has uncontrolled hypertension, weakness in the extremities is a sign of cerebral involvement with the risk for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload, which may be associated with heart failure due to hypertensive crisis, but they are not medical emergencies. Crackles throughout the lung fields with acute onset of dyspnea and orthopnea would indicate acute pulmonary edema, which would also be considered a medical emergency requiring immediate action.

The nurse is teaching a group of women in a community clinic about osteoporosis. Which explanation should the nurse include? A. It is important to increase calcium intake and weight-bearing exercise. B. Ice, rest and ibuprofen will help with the symptoms of osteoporosis. C. Performing regular range-of-motion exercises will help with inflamed joints. D. It is best to avoid foods high in purine, such as bacon, liver and shellfish.

A Osteoporosis (OP) is a chronic, progressive metabolic bone disease marked by low bone mass and the deterioration of bone tissue, leading to bone fragility and an increased risk of fractures. Care focuses on proper nutrition, calcium supplementation, exercise, drugs and the prevention of falls.Osteoporosis is often mistaken for osteoarthritis (OA). Ice, rest, NSAIDs and range-of-motion exercises are used to treat symptoms of OA and/or Rheumatoid Arthritis (RA).Purine-rich foods need to be avoided with gout. Purine-rich foods increase uric acid production, which worsens the symptoms of gout.

A nurse is teaching the parent of a 9 month-old infant about diaper dermatitis. Which of these actions would be appropriate for the nurse to include during the teaching? A. Stop any new food that was added to the infant's diet prior to the rash B. Use commercial baby wipes with each diaper change C. Do not use occlusive ointments on the rash D. Use only cloth diapers that are rinsed in bleach

A The addition of new foods to the infant's diet commonly can cause diaper dermatitis. The other actions are incorrect to deal with this problem.

The adult client is alert and cooperative. The client has a short leg cast and can only partially bear weight on the casted leg. Which technique can be safely used to transfer the client from the bed into a chair? A. One caregiver applies a transfer belt and uses the stand-and-pivot technique B. One caregiver applies a gait belt and transfers the client toward the weak side C. Two caregivers lift the client from the bed and move the client into the chair D. Two caregivers use a friction-reducing device and wide base of support when transferring the client

A The algorithm for safe client handling and transferring an alert and cooperative client to a chair states: one caregiver applies a gait/transfer belt, uses the stand-and-pivot technique and transfers the client toward the strong side. A friction-reducing device is placed under the client to assist in turning or moving the person in bed, not transferring to a chair. A two person lift is unsafe.

A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? A. Trends in daily weights B. Skin turgor over at least two areas of the body C. Changes in mucous membrane moistness D. Difference between intake and output

A The most accurate indicator of changes in fluid balance is the daily weight. A 1-kilogram (or 2.2 pounds) of weight gain is equal to approximately 1000 mL of retained fluid. Other options are considered as part of data collection for fluid balance, but they are not the most accurate indicators of fluid balance.

The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a priority? A. Altered parenting B. Social isolation C. Ineffective coping D. Sexual dysfunction

A The mother who abuses cocaine puts her newborn and any other children at risk for neglect and abuse. The continued use of drugs has the potential to impact parenting behaviors. Social service referrals are indicated for evaluation and follow-up.

A nurse is providing information to a young adult client recently diagnosed with testicular cancer and asks the client to state his understanding of the disease. Which of the statements made by the client indicates a need for additional correct information? A. "If I have cancer at stage III it means I have a better chance of recovery than if it were stage I or II." B. "After surgery, I can have a prosthesis placed inside my scrotum that will look and feel like the real thing." C. "The surgeon will remove one or both of my testicles and maybe the lymph nodes in my lower belly, too." D. "I may want to have my sperm frozen and preserved before starting chemotherapy."

A There are five stages of testicular cancer, ranging from Stage 0 to Stage IV; the higher the number, the more extensive the disease. Stage III testicular cancer means the cancer has spread beyond the lymph nodes (possibly to the liver, lungs or brain). The information in the other statements indicates appropriate understanding of this diagnosis and its treatment.

The client who is diagnosed with autism begins to eat the food on his plate using his hands. Because the client regularly uses utensils to eat his food, which response by the nurse would be best? A. Place the spoon in the client's hand and state, "Use the spoon to eat your food." B. Make the comment: "I believe you know better than to eat with your hands." C. Remove the food and state: "You can't have anymore food until you use the spoon." D. Jokingly state: "Well I guess fingers sometimes work better than spoons."

A This action identifies instruction and verbal expectation with adaptive behavior. The other options are incorrect and non-therapeutic approaches.

A nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. Which intervention should the nurse take first? A. Assess the family's patterns for dealing with death B. Ask about their present religious affiliations C. Explain the stages of death and dying to the family D. Recommend an easy-to-read book on grief

A When a new problem is identified, it is important for the nurse to first collect accurate information. This is crucial to ensure that the client and the family's needs are adequately identified in order to plan and implement nursing care. Once the situation has been assessed and a plan has been established, the nurse can focus on teaching or referral to other resources.

A client is transported by a family member to the emergency department following a boating accident. The client is conscious, shivering, and confused. The client is still wearing wet clothes. Which interventions does the nurse implement? (Select all that apply.) A. Apply warm blankets B. Monitor vital signs C. Infuse warm IV solutions as ordered D. Remove wet clothes E. Massage cold extremities F. Give sips of warm fluids

A,B,C,D This client is at risk for hypothermia. In a conscious client, wet clothing should be removed carefully. External rewarming, using blankets or heat packs placed under the arms and on the neck, chest, and groin, is appropriate. In-hospital treatment also includes monitoring core temperature and cardiac rhythm, ventilating with warm humidified air/oxygen to help stabilize core temperature and administering warm IV fluids. Sips of warm fluids may be given to the conscious and alert client only after his condition is stabilized. Extremities should never be massaged.

The nurse is collecting data from an adolescent client. Which of the following issues should the nurse address? (Select all that apply.) A. "Where are you currently living?" B. "How are things going at home?" C. "Have you decided what you are going to do after high school?" D. "Are you currently having conflicts with someone close to you?" E. "How many sexual partners have you had in the past six months?" F. "Have you gotten in any trouble lately?"

A,B,D,E Several professional organizations have published guidelines aimed at improving and maintaining health care for adolescents and young adults. The American Academy of Pediatrics, American Academy of Family Physicians, American Medical Association and U.S. Preventive Services Task Force have similar guidelines for health supervision of adolescents. These guidelines emphasize the need to provide health services to adolescents that meet their physical and emotional needs. Bright Futures (American Academy of Pediatrics, 2017) emphasizes that the following issues should be addressed with adolescents at each health visit: Physical growth and development (physical and dental health, body image, healthy nutrition, physical activity) Social and academic competence (relationships with peers and family, school performance, interpersonal relationships) Emotional well-being (mental health, sexuality) Risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs) Violence and injury prevention Closed-ended questions about the client's plans after high school and if they have been in trouble are non-therapeutic and not appropriate in this situation.

The client is admitted in stable condition from the emergency department. Based on the ECG strip, the nurse anticipates which of the following types of medications will be ordered? (Select all that apply.) Strip shows Atrial Flutter A. Calcium channel blocker B. Beta blocker C. Diuretic D. Vasodilator E. Cardiac glycoside

A,B,E This ECG depicts atrial flutter, when the atria beat excessively fast (250-300 BPM). Medications used to slow the heart include calcium channel blockers (such as diltiazem), beta-adrenergic blockers (such as propranolol), and a cardiac glycoside (digoxin). An anticoagulant (such as warfarin) may also be ordered. Vasodilators and diuretics are used to lower blood pressure; vasodilators will increase heart rate.

The nurse attends an interdisciplinary meeting on the topic of fall prevention. What specific tactics can be used to reduce falls in health care settings? (Select all that apply.) A. Use "low beds" for at-risk clients B. Raise all side rails C. Install and use bed alarms D. Identify vulnerable clients E. Use a "two to transfer" policy F. Regularly reorient clients

A,C,D,E Fall prevention involves managing a client's underlying fall risk factors and then implementing strategies to reduce falls. Using restraints, including side rails, can actually increase the risk of fall-related injuries and deaths. Clients with neurocognitive disorders cannot process the information we provide when we attempt to reorient them to our reality. The other techniques listed are used (in combination) to help prevent falls in health care facilities.

A mother of a burned child asks the nurse to clarify what is meant by a third-degree burn. The best response by the nurse should include which point? A. "The top layer of the skin is destroyed." B. "All layers of the skin were destroyed in the burn." C. "The skin layers are swollen and reddened." D. "Muscle, tissue and bone have been injured."

B A third-degree burn is a full thickness injury to dermis, epidermis and subcutaneous tissue.

The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment? A. Dusky in color with poor skin turgor over abdomen B. Pale skin, thin arms and legs, and uninterested in surroundings C. Irritable and "colicky," making no attempts to turn or sit up D. Alert, laughing, playing with a rattle, and sitting with support

B Diagnosis of NOFTT is weight consistently below the 3rd to 5th percentile for age and gender, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of two major growth parameters in a short period of time. The nurse would expect to see a child who avoids eye contact, has pale skin, thin arms and legs, and is easily fatigued. NOFTT is due to psychosocial problems such as neglect, lack of knowledge about proper feeding or of the infant's needs. Many times the child engages in self-stimulatory behaviors (head banging or rocking) and is wary of close contact with people.

A nurse is teaching a client about digoxin toxicity. Which statement made by the client is incorrect and indicates more teaching is needed? A. "High levels of digoxin can cause vision changes." B. "I must immediately report a strong pulse of 62 bpm." C. "I should report nausea and vomiting lasting more than a few days." D. "I'll let you know if my pulse feels uneven and misses beats."

B Digoxin helps to make the heart beat stronger and with a more regular rhythm, which is why clients should understand that they should not take the drug if their pulse rate is less than 60 (or above 100). Clients should know to report the common symptoms of digoxin toxicity, such as irregular pulse, loss of appetite, nausea and vomiting and vision changes. The nurse needs to help the client understand that he or she does not need to contact the health care provider when his or her pulse is 62 bpm.

The nurse is caring for a client who received tenecteplase to open an occluded coronary artery following an acute myocardial infarction. Which finding should cause the greatest concern for the nurse? A. Red-colored tint of the urine B. Hematemesis C. Pink frothy sputum D. Serosanguineous drainage from gums

B Hemorrhage, or bleeding, is the most common risk associated with any thrombolytic. Tenecteplase (TNKase) is currently indicated for the management of acute myocardial infarction (AMI). Minor bleeding from the gums or nose can occur in about 25% of people who receive these drugs. Remember that the spelling of many of the generic thrombolytic agents end with "ase."

A young child is receiving treatment for lead poisoning. Which of the following is the most serious effect of long-term exposure to lead? A. Impaired kidney function B. Damage to the central nervous system C. Anemia and fatigue D. Lead colic and constipation

B Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior, and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment.

A client diagnosed with hypertension is started on atenolol. The nurse should instruct the client to immediately report which of these findings? A. Feeling tired B. Slow, irregular pulse C. Decreased sex drive D. Insomnia

B Most of the side effects for the beta-blocker, atenolol (Tenormin) are transient or mild, such as decreased sex drive, low energy or feeling tired, depression or insomnia. However the client should understand that he needs to call the health care provider if he experiences any of these serious side effects: slow or uneven heartbeats, feeling short of breath, lightheadedness, fainting, or swelling of the feet or ankles.

The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? A. It can cause severe headaches B. It may no longer work as well C. It will cause profound hypotensive effects D. It will irritate the skin

B Nitroglycerin patches may not work as intended when they are used continuously. To prevent tolerance to the medication, clients should apply a patch once a day and remove it after 12 to 14 hours. Some of the more common side effects of wearing a nitroglycerin patch may include headache, dizziness, lightheadedness, nausea, redness or irritation of the skin that was covered by the patch.

During a routine checkup, a client with a history of type 1 diabetes mellitus has the glycosolated hemoglobin (HbA1c) checked. The results indicate a level of 11%. Based on this result, what should the nurse emphasize during teaching? A. Rotation of injection sites B. Daily peripheral glucose monitoring C. Insulin mixing and preparation D. Review of diet and exercise recommendations

B Normal results for Hg A1c (glycosolated hemoglobin) is 6% or less. Persons diagnosed with diabetes mellitus have guidelines designated by their health care provider; usually it's less than 7%. Hemoglobin A1c is an average serum glucose level for the prior three months. The peripheral stick for glucose is an approach to monitor daily fluctuations.

The health care team is meeting to discuss discharge planning for a client following total hip replacement surgery. Which assessment finding is most important for the nurse to share? A. The client does not like the taste of the oral potassium supplement medication B. The home is a two-story and all bedrooms and bathroom are located upstairs C. The adult daughter will be responsible for shopping and driving the client after discharge D. The partner expresses some discomfort with the dressing change

B Nurses, because of the intimate work with clients, often discover important personal information that impacts discharge planning. It is important to share these insights and findings to assure client's needs are met when they go home. The client with major orthopedic surgery can expect some mobility impairment after discharge, so the physical characteristics of the home are critical to activities of daily living and safety. The other findings are helpful in planning but are not as critical to safety as the issue of stairs and access. Safety issues take priority.

The nurse is assessing a client with a history of hypertension. Which of these questions is a priority for the nurse to ask? A. "Describe your usual exercise and activity patterns." B. "What over-the-counter medications do you take?" C. "Describe your family's cardiovascular history." D. "Tell me about your usual diet for one day."

B Over-the-counter medications (OTC), especially those that contain cold preparations, can increase the blood pressure to the point of aggravation of the hypertension. The nurse would ask the other questions, but the answers to these questions don't have as great a risk for the client as the question about OTC medications.

A diabetic client asks the nurse: "Why did the health care provider order a glycosylated hemoglobin (HbA1c) measurement? My blood glucose reading was just done this morning." Which explanation would be best to help explain the purpose of the HbA1c? A. Provides a more precise blood glucose value than self-monitoring B. Reflects an average blood glucose for the prior several months C. Is performed to detect any complications of diabetes D. Measures the circulating levels of insulin

B The HbA1c is used to determine how well the client is managing the disease. The results reflect the average blood sugar level for the past 2 to 3 months; the more glucose in the blood, the more hemoglobin gets glycated (coated with glucose). The higher the HbA1c, the poorer the glucose management and the higher the risk of diabetic complications. For most diabetics, the goal is to keep the HbA1c at or below 6.5 - 7 %.

A client diagnosed with testicular cancer is scheduled for a right orchiectomy. The nurse is able to answer the client's questions about this procedure with the understanding that a unilateral orchiectomy involves which of the following approaches? A. A dissection of related lymph nodes by the testes B. A surgical removal of one testicle C. A partial surgical removal of the perineal area D. A surgical removal of the entire scrotum

B The affected testicle is surgically removed along with its tunica and spermatic cord. The other genitals and the perineal area are not involved.

A nurse arranges for an interpreter to facilitate communication between a health care team and a non-English speaking client. To promote clearer communication, which of these would be an appropriate action for the nurse to use when working with an interpreter? A. Plan that the encounter will take more time than if the client spoke English B. Promote verbal and nonverbal communication with both the client and the family C. Speak only a few sentences at a time and then pause for a few moments D. Ask the client to speak slowly and to look at the person spoken to

B The nurse should communicate with the client and the family and not with the interpreter. Culturally appropriate eye contact, gestures and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact, if culturally correct, with both the client and interpreter to elicit feedback and to read nonverbal cues.

The nurse is reviewing the medical records for a newborn and sees that the first APGAR score was an 8 and the second score was a 9. Which category of the APGAR test is most likely the reason for the improved score? A. Muscle tone B. Color C. Cry D. Heart rate

B There are five categories of the APGAR test and each category is scored with a 0, 1, or 2, depending on the observed condition. If the body is pink and the extremities are blue (acrocyanosis), the infant scores 1 in the "skin color" category. This is the most common APGAR score deduction.

The parents of a 4 year-old hospitalized child tell the nurse, "We are leaving now and will be back at 6:00 pm." A few hours later the child asks a nurse when the parents will come again. What is the best response by the nurse? A. "When the clock hands are on the numbers 6 and 12." B. "They will be back right after you eat supper." C. "In about two hours, you will see them." D. "After you play awhile, they will be here."

B Time is not completely understood by preschoolers. Preschoolers interpret time with their own frame of reference of activities that they have experienced. Thus, it is best to explain time in relationship to a known and common event.

A client who is a victim of domestic violence states, "If I were better, I would not have been beaten." Which feeling best describes what the client may be experiencing at this time? A. Rejection B. Self-blame C. Helplessness D. Fear

B Victims of domestic violence may be immobilized by a variety of affective responses with one being self-blame. These clients often believe that a change in their behavior will cause the abuser to become nonviolent. They may even have been told this by their abuser. This is an untrue but not uncommon myth.

A nurse is teaching a client with atrial fibrillation about the use of warfarin at home. The nurse should reinforce the need to avoid which of the following? A. Exposure to sunlight B. Foods rich in vitamin K C. Large indoor gatherings D. Active physical exercise

B Vitamin K acts as an antidote to the pharmacologic action of warfarin therapy and will decrease its effectiveness. Foods high in vitamin K include dark green leafy vegetables, tomatoes, bananas, cheese and fish.

The nurse is performing an assessment on an infant with severe airway obstruction. Which assessment finding would the nurse anticipate? A. Rapid, shallow respirations B. Nasal flaring C. Chest pain aggravated by respiratory movement D. Cyanosis and mottling of the skin

B When the trachea or bronchioles become partially blocked, air flow is restricted. Nasal flaring is an exaggerated opening and closing of the nostrils with breathing, and is considered a subtle but important sign of acute respiratory distress in an infant. This is an emergency and requires rapid medical intervention.

The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? A. An oatmeal cookie B. A cup of yogurt C. A slice of wheat bread D. A cup of cereal

B and C are both correct Celiac disease is an autoimmune disease that occurs in genetically predisposed people, where the ingestion of gluten leads to damage in the small intestine. Gluten is a general name for the proteins found in wheat, rye, barley and triticale (a cross between wheat and rye). Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected. Children or adults with celiac disease should eat a gluten-free diet. An oatmeal cookie, wheat bread and cereal contain gluten and should be avoided. Dairy products are generally considered gluten-free and are an appropriate snack choice for the child.

A client with chronic kidney disease (CKD) is scheduled for hemodialysis at 9 am. It is now 6:30 am and the client is eating breakfast. How should the nurse help the client to prepare for hemodialysis? (Select all that apply.) A. Hold all oral medications B. Administer prescribed vitamin D C. Administer prescribed phosphate binder D. Weigh the client E. Assess patency of the access site F. Ensure the client eats a high fiber, high protein breakfast

B,C,D,E The nurse should administer a phosphate binder, such as sevelamer, with breakfast. Vitamin D may be prescribed with the phosphate binder to help control both serum calcium and phosphate levels. Some medications will be withheld; dialyzable meds and meds that lower blood pressure are held until after the procedure. The client should eat an easily digestible meal at least 2 hours before treatment begins, avoiding foods high in fiber or protein. The nurse should assess the patency of the access site (for presence of bruit, palpable thrill, distal pulses, and circulation), weigh the client, and measure vital signs.

A respiratory therapist (RT) is collecting an arterial blood gas (ABG) sample. The RT must respond to an emergency and asks the nurse to manage the puncture site. Which actions should be completed? (Select all that apply.) A. Thoroughly wash the site with saline, then apply an antibacterial solution B. Check for distal capillary refill C. Apply snug gauze and secure with tape D. Remove dressing in one hour E. Apply pressure for 5 to 10 minutes

B,C,E Five to 10 minutes of pressure ensures adequate coagulation at the site. Checking capillary refill indicates if there are any changes to blood flow to the hand. The dressing can be removed prior to the next stick or within 24 hours.

The parent of an 8-month-old infant asks the nurse if the child's language development is normal for this age. Which sounds should the nurse expect at this age? (Select all that apply.) A. Single vowel sounds such as ah, eh and uh B. Combining syllables (e.g., "dada") C. Cooing, gurgling and laughing aloud D. Imitating sounds E. Crying for 1-1 1/2 hours per day

B,D In the first few weeks of life, crying has a reflexive quality and is mostly related to the child's physiologic needs. Infants cry for 1-1 1/2 hours per day until up to 3 weeks of age and then build up to 2 hours and even 4 hours by 6 weeks of age. Crying tends to decrease by 12 weeks. Normal infant language development milestones: Around 2 months: Single vowel sounds such as ah, eh and uh By 3-4 months: Cooing, gurgling and laughing aloud By 6 months: Imitating sounds and combining syllables (e.g., "dada")

A novice charge nurse is delegating duties. Which tasks, if delegated to an unlicensed assistive personnel (UAP), would require intervention by the nurse manager? A. To empty a urethral collection bag B. To feed a 2 year-old with a broken arm C. To bathe a woman with internal radon seeds and device D. To help an older adult client to the bathroom

C A client with internal radiation is complex care and is not suitable to be assigned to a UAP. Additionally, the client would not receive a complete bath because movement is minimized during this therapy to prevent the slippage of the device.

A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take Alka-Seltzer for an upset stomach?" What is the best response by the nurse? A. "Use about half the recommended dose of Alka-Seltzer." B. "Select another antacid that does not inactivate warfarin (Coumadin)." C. "Avoid Alka-Seltzer because it contains aspirin." D. "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)."

C Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin is an antiplatelet drug and taking this with warfarin will potentiate the anticoagulant effects of warfarin (Coumadin), which may increase the risk of bleeding.

A pregnant woman is advised to increase the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet best satisfies the client's requirements? A. 1 cup macaroni, 3/4 cup peas, glass whole milk, medium pear B. 3 ounces chicken, 1/2 cup corn, lettuce salad, small banana C. Beef, 1/2 cup lima beans, 8-ounce glass of skim milk, 3/4 cup strawberries D. Scrambled egg, hash browned potatoes, large nectarine

C Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good source of Vitamin C.

A 55 year-old woman is taking prednisone and aspirin (ASA) as part of the treatment for rheumatoid arthritis. Which approach would be an appropriate intervention for the nurse? A. Assess the pulse rate every four hours B. Monitor tBoth prednisone and ASA can lead to gastrointestinal bleeding. Therefore, monitoring for occult blood is indicated.he level of consciousness every shift C. Test stools for occult blood D. Discuss fiber in the diet to prevent constipation

C Both prednisone and ASA can lead to gastrointestinal bleeding. Therefore, monitoring for occult blood is indicated.

An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident (CVA) has had a blood pressure of 160/100 to 180/110 over the past two hours. The nurse has also noted increased lethargy since admission. Which of the following new findings should the nurse report immediately to the provider? A. Rapid pulse B. Incontinence C. Slurred speech D. Muscle weakness

C Changes in speech patterns and level of conscious are indicators of potential continued intracranial bleeding or extensions of a stroke. Further diagnostic testing may be indicated. Recall the word "FAST" with stroke findings: "F" is for changes in the face such as drooping of corner of the eye or mouth, "A" is for a drifting down of one arm when the arms are raised to shoulder height, "S" is for slurred speech and "T" is to telephone 911.

A nurse has administered several blood transfusions over three days to a 12 year-old client with thalassemia. What lab value should the nurse monitor during this therapy? A. Reticulocyte count B. Platelet count C. Hemoglobin D. Red blood cell indices

C Children with beta thalassemia major will usually require blood transfusions about every three to four weeks throughout their life. Transfusions help maintain hemoglobin at a high enough concentration to provide oxygen to the body and prevent growth abnormalities and organ damage; therefore, the nurse should monitor hemoglobin following a transfusion. A reticulocyte count is used as a diagnostic tool (to help rule out iron-deficiency anemia). Monitoring platelets would be indicated following transfusion of platelets.

A client with heart failure has digoxin ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A. Decreased chest pain with decreased blood pressure B. Increased heart rate with increased respirations C. Improved respiratory status with increased urinary output D. Diaphoresis with decreased urinary output

C Digoxin (Lanoxin), a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia or tachycardias above 120, arrhythmia, visual or gastrointestinal disturbances. Clients being treated with digoxin should have the apical pulse evaluated for one full minute prior to the administration of the drug.

A nurse and a client are talking about the client's progress towards understanding the client's behaviors during stressful situations. This is typical of which phase in a therapeutic relationship? A. Orientation B. Termination C. Working D. Pre-interaction

C During the working phase, alternative behaviors and techniques are explored mutually with a nurse and a client. A discussion of the meaning behind behaviors is one of many approaches during the working phase.

A child is sent to the school nurse by a teacher who has a written note that fifth disease is suspected. Which of the following should the nurse expect to find if the child has this condition? A. Macule that rapidly progresses to papule and then vesicles B. Discrete rose pink macules will appear first on the trunk and fade when pressure is applied C. Bright red cheeks, with a "slapped face" appearance D. Koplik spots appear first followed by a rash that appears first on the face and spreads downward

C Fifth disease is also referred to as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. It is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases that all have similar rashes. The other four diseases are measles, rubella, scarlet fever and Dukes' disease. People will not know that a child has parvovirus infection until the rash appears, and by that time the child is no longer contagious.

A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective? A. "The inhaler can be used whenever I feel short of breath." B. "If I forget a dose, I can double up on the next dose." C. "I should rinse my mouth after using the inhaler." D. "I should not use a spacer with my inhaler."

C Fluticasone inhaled (Flovent Diskus) is an inhaled corticosteroid used to prevent asthma attacks. It is often used in conjunction with a bronchodilator. The client should be instructed to rinse the mouth after using the inhaler to wash away any steroid residue so as to reduce the risk of oral fungal infections.

There is an order to insert a urinary catheter. The client is an adult female. The nurse slips the catheter approximately 4-5 inches (10-12 cm) into an opening, but no urine is obtained. What is the most probable reason for this outcome? A. No urine is present in the bladder B. The catheter is not inserted far enough into the canal C. The catheter is located in the vaginal canal D. The bladder is overdistended without the ability to empty

C For an adult female, a urinary catheter is inserted about 2-3 inches (5-7 cm) in the urinary meatus until the urine flow begins. If urine does not flow, the catheter can be rotated gently and carefully inserted a bit further. When a catheter is inserted 4-5 inches (10-12 cm) with no urine return, the catheter is probably in the vaginal canal.

The home health aide calls the nurse to report information about a client. Which of these findings should the nurse act on? A. "The client reports not sleeping well for the past week." B. "The partner says the client has gotten slower when doing things every other day." C. "The urine in the urinary catheter bag is of a deeper amber, almost brown color." D. "The family wants to discontinue the home meal service called Meals on Wheels."

C Home health aides often report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs that require immediate action and follow-up. The most significant finding is the color of the urine for the one client; this requires follow-up and additional data collection prior to contacting the health care provider. The other options may need further assessment but are not the priority.

The nurse is assessing a client who takes a prescribed antipsychotic medication. Which findings require immediate discontinuation of this medication? A. Cheek puffing and involuntary movements of extremities and trunk B. Agitation and constant state of motion C. Hyperthermia and severe muscle rigidity D. Involuntary rhythmic stereotypic movements and tongue protrusion

C Hyperthermia, severe muscle rigidity, and malignant hypertension are findings associated with neuroleptic malignant syndrome (NMS). This is a serious complication of the use of antipsychotic drugs; even the newer atypical antipsychotics can cause NMS.

A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal at this time? A. Peanut butter and jelly sandwich, chips, pudding, milk B. Hot dog, carrot sticks, gelatin, milk C. Soup, blenderized soft foods, ice cream, milk D. Baked chicken, applesauce, cookie, milk

C In a child with cleft palate repair several days ago, parents should prepare soft foods. Any foods with particles that might traumatize the surgical site should be avoided. The other choices include items such as carrots, chips and cookie and are either stiff or rough types of food.

A client is admitted to the emergency department during an acute asthma attack. Which assessment finding would support this diagnosis? A. Loose, productive cough B. Fever and chills C. Diffuse auditory expiratory wheezing D. Forced expiratory volume (FEV1) 60% of the predicted value

C In asthma, two situations are of concern. First, the airways are narrowed making it difficult to get air into the lungs, resulting in wheezing. An auditory wheeze is one that is heard with normal hearing of the ear without a stethoscope. This is an emergency situation. The second concern is thick, tenacious secretions. A forced expiratory volume (FEV1) is very concerning if it is 50% of predicted. Fever and chills are not consistent with asthma attacks.

Which management style best demonstrates the end of the continuum of management behaviors referred to by Douglas McGregor as Theory Y? A. The manager takes a hands-off attitude and makes no decisions for employees B. The manager is responsible for motivation of employees toward the organizational goals C. The manager assumes employees are self-motivated and want to work toward organizational and personal goals D. The manager organizes teams of staff and gives compensation to the team rather than individual success

C McGregor's theory placed management behaviors on a continuum, with Y being a set of propositions that describes managers as supporting people who naturally work for organizational and personal goals.

A nurse is caring for a client with schizophrenia who has been treated with quetiapine for one month. Today the client is increasingly agitated and reports having muscle stiffness. Which of these additional findings should be reported to the health care provider? A. Decreased pulse and blood pressure B. Mental confusion and general weakness C. Elevated temperature and sweating D. Muscle spasms and seizures

C Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increased creatine phosphokinase (CPK). This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications.

The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted with a connection to a ventilator. Which finding should prompt the nurse to take immediate action to resolve the issue? A. Client is unable to speak B. Mist is visible in the T-Piece of the ventilator circuit C. Pulse oximetry of 86% saturation D. Breath sounds are heard bilaterally

C Pulse oximetry should not be lower than 90% saturation. Breath sounds are heard bilaterally so the placement of an ET is most likely in proper position. The ventilator settings will need to be rechecked. A client with an ET tube in place will not be able to talk when the ET tube balloon is inflated.

The nurse is having difficulty reading the health care provider's written order that was written just before the shift change. What action should the nurse take? A. Leave the order for the oncoming staff to follow up on B. Ask the pharmacy for assistance in the interpretation C. Call the provider for clarification of the order D. Contact the charge nurse for an interpretation

C Relying on another's interpretation is very risky. When in doubt, check with the health care provider who wrote the difficult-to-read order. Order entry systems help to minimize these types of problems.

A client reports taking lithium as prescribed. Which of these findings indicate early signs of lithium toxicity? A. Electrolyte imbalance, tinnitus and cardiac arrhythmias B. Pruritus, rash and photosensitivity C. Vomiting, diarrhea and lethargy D. Ataxia, agnosia and course hand tremors

C Serum lithium levels should be between 0.8 - 1.2 mEq/L (remember, the exact numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with increasing serum lithium levels, but clients may exhibit toxic finding at lithium levels below 2.0 mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels.

The nurse is using the Glasgow Coma Scale (GCS) to assess a client who experienced a head injury. During the last assessment, the client scored a 14. Now the client opens eyes to verbal command (GCS 3), has purposeful movement to painful stimulus (GCS 5) and is using inappropriate words (GCS 3). Which intervention by the nurse should be implemented first? A. Continue to monitor level of consciousness B. Raise the head of the bed C. Call the rapid response team and health care provider D. Increase the flow of oxygen

C The GCS measures the client's highest motor response, verbal response, and eye response (scores range from 3 to 15). The GCS can be used to help measure progress and predict a client's outcome or prognosis. A decreased score of 2 or more indicates "neuroworsening" and a need for urgent intervention. It's possible the change is due to increased intracranial pressure (ICP), but this needs to be determined first before other actions are taken.

A nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. What should be the nurse's first action? A. Prepare for immediate defibrillation B. Notify the rapid response team and the health care provider C. Assess airway, breathing and circulation D. Begin cardiopulmonary resuscitation

C The nurse must treat the client, not the cardiac monitor. Always assess the client first to determine the appropriate next step. Check the client's ABCs. Findings of chest pain, dyspnea, hypotension, or an altered level of consciousness may indicate a decrease in cardiac output and a need for cardioversion and other emergency interventions.

Several hours after a gastrectomy, the nasogastric tube (NGT) stops draining. After referring to the standing gastrectomy postoperative orders, what order will the nurse implement first? A. Notify the surgeon B. Increase the amount of suction C. Gently irrigate the tube with sterile normal saline D. Reposition the tube until it begins to drain

C The nurse will assess the position and patency of the NGT, as well as the color and amount of gastric drainage. The nurse can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or repositioning the tube is needed, the nurse must call the surgeon. The NGT inserted in surgery should not be repositioned by the nurse because of the risk of disrupting any internal sutures. The NGT should be connected to low suction; it would be contraindicated to increase the suction.

A nurse is caring for a client with renal calculi. Which focus of the health care provider's orders would be a priority? A. Push oral fluids and keep open IV rate B. Start intravenous antibiotics after blood draw for culture and sensitivity C. Morphine sulfate using patient-controlled analgesia D. Apply continuous warm compresses to the flank area

C The priority action is to administer narcotic analgesics, which will provide prompt relief of the severe pain caused by kidney stones. Intravenous fluids will help with hydration and if the client isn't vomiting, oral fluids (two to three quarts a day) will help move the stone through the urinary system.

A client tells the nurse that the client is fearful of the planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse? A. Deny the feelings B. Call a chaplain C. Listen to the client D. Cite recovery statistics

C Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, the nurse's acceptance of feelings should be followed by questions about the client's beliefs.

A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the most therapeutic in response to the client's attire? A. Tactfully explain appropriate clothing for the unit meetings B. Quietly point out to her how the other clients are dressed on the unit C. Straightforwardly assist the client to her room for appropriate apparel D. Gently remind her that she is no longer on stage

C This action assists the client to maintain self-esteem while modifying her behavior. The other options would result in embarrassment or possibly conflict.

The nurse assesses a newborn one day after birth, noting a high-pitched cry, irritability and lack of interest in feeding. The mother has left the hospital against medical advice. What intervention is appropriate nursing care at this time for the newborn? A. Talk to the newborn while feeding B. Offer formula every two hours C. Reduce the environmental stimuli D. Rock the baby frequently

C This newborn appears to be exhibiting withdrawal symptoms, possibly due to substances taken by the mother before birth. Other findings of neurologic excitability include tremors, exaggerated Moro reflex, frequent yawning and sneezing and increased wakefulness. Reduction in the noise and light will reduce the central nervous system stimulation.

A nurse is observing a client during an excretory urogram. Which of these observations indicate there is a complication? A. Within two minutes of the dye injection the client states, "I have a feeling of getting warm." B. A client complains of a salty taste in the mouth when the dye is injected C. Within one minute after the dye is injected the client's entire body turns a bright red color D. Five minutes into the procedure the client gags and states, "I am getting sick."

C This observation suggests anaphylaxis from the dye injection, which can cause massive vasodilation and shock. Other findings of anaphylaxis are immediate wheezing and/or respiratory arrest. The salty taste in the mouth, the feeling of warmth and the complaint of nausea are expected side effects of the injection of the dye.

A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness would the nurse recognize as increasing the risk of developing Reye's syndrome? A. Rubeola B. Meningitis C. Influenza D. Hepatitis

C Varicella (chickenpox) and influenza are viral illnesses that have been identified as increasing the risk for Reye's syndrome. Use of aspirin with viral infections is contraindicated in children (from birth to 19 years of age) as it increases the risk of developing Reye's syndrome.

The client is prescribed warfarin (Coumadin, Jantoven). Which lab test would the nurse monitor to determine a therapeutic response to the drug? A. Partial thromboplastin time (PTT) B. Bleeding time C. International Normalized Ratio (INR) D. Coagulation time

C Warfarin dosage is based on the result of a client's daily INR (or prothrombin time [PT]). Warfarin affects the function of the coagulation cascade and helps inhibit the formation of blood clots. The goal of warfarin therapy is to maintain a balance between preventing clots and causing excessive bleed, which is why careful monitoring is needed.

A 38 year-old female client is admitted to the hospital diagnosed with an acute exacerbation of asthma. This is her third admission for asthma in seven months and she admits she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A. The client will experience frequent bouts of pneumonia B. The alveoli will degenerate and balloon out C. Lung remodeling and permanent changes in lung function will result D. Chronic bronchoconstriction of the large airways will occur

C While an asthma attack is an acute event from which lung function essentially returns to normal. Chronic undertreated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema, which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways and lead to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help reinforce the need for daily management of the disease whether the client "feels better" or not.

A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of voiding on the floor by which of these approaches? A. Require the client to mop the floor after each incident B. Restrict the client's fluids throughout the day C. Toilet the client more frequently with supervision D. Withhold privileges each time the voiding occurs

C With a client that has altered thought processes, the appropriate nursing approach to change behaviors is to take an active role in attending to the physical needs of the client. The other options are incorrect approaches.

The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress disorder (PTSD). What priority interventions shall the nurse include in the client's plan of care? (Select all that apply.) A. Place the client in a secluded area away from others. B. Medicate the client with a sedative while they experience flashbacks. C. Assign the same staff to the client as often as possible. D. Stay with the client during periods of flashbacks and nightmares. E. Encourage the client to talk about the trauma at their own pace. F. Discuss the coping strategies the client is using in response to the trauma.

C,D,E,F Trauma-related disorders such as PTSD can be described as the client's reaction to an extremely distressing experience, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, or being the victim of torture, terrorism, rape or other crimes that cause severe emotional shock and have long-lasting psychological effects.Interventions that are considered trauma-informed highlight the importance of respect for the client, collaboration and connection, providing information about the connections between trauma and other health concerns, instilling hope and empowering the trauma survivor to guide and direct their recovery plan.A PTSD client may be suspicious of others in their environment. It is a priority to facilitate building a trusting relationship. The presence of a trusted individual may reassure the client and calm their fears for their personal safety. Debriefing or talking about the traumatic event is the first step in the client's progression toward resolution. The long-term resolution of the client's post-traumatic response is largely dependent on the effectiveness of the client's coping strategies.Interventions such as seclusion may be retraumatizing to a client with a history of trauma and are only indicated if the client exhibits behavior that presents imminent risk of harm to themselves or others.Administering a sedative without a clear, clinical indication is considered a chemical restraint. This should never be used for the convenience of the staff or as a punishment. The nurse should first try other measures to decrease agitation such as talking down (verbal intervention).

A client is admitted to the hospital with a diagnosis of deep vein thrombosis (DVT). During the initial assessment, the client reports sudden shortness of breath. The oxygen saturation reading is 87%. At this time what is the highest priority nursing intervention? A. Administer the PRN albuterol nebulizer B. Begin continuous cardiac monitoring C. Call the health care provider (HCP) D. Administer oxygen to maintain a saturation of 92%

D Acute dyspnea and hypoxia is a classic finding with pulmonary embolism, when a clot lodges in the lung that has broken off from the DVT. Administration of oxygen to correct the hypoxia is the highest priority Albuterol nebulization is a standard treatment for respiratory distress related to asthma, COPD and anaphylaxis, but it is not used for dyspnea due to other causes (such as PE.) The HCP will need to be called and the nurse should anticipate orders for diagnostic tests (for example ECG, chest x-ray) and other medical interventions.

A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority? A. Show the mother films on the physiology of lactation B. Give the mother several illustrated pamphlets C. Give the mother privacy for the initial feeding D. Assist the mother to position the newborn at the breast

D All of the approaches should be helpful in teaching. However, the priority is to place the infant to the breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.

A 14 month-old infant is brought to the emergency department with irritability, lethargy over two days, dry skin, and increased pulse. What additional question would be most important for the nurse to ask in assisting the provider with determination of the diagnosis? A. Use of daycare B. Reverse of sleep-wake cycles C. Change in eating habits D. The number of wet diapers in the past two days

D Based on these clinical findings, the nurse might suspect that the infant is dehydrated. Asking about the number of wet diapers would assess for decreased urine output, a key finding in dehydration. Asking about increased concentration of the urine would also be appropriate. The other questions, while appropriate, would not provide the most helpful diagnostic information.

The nurse notes that a prescription for captopril was changed to losartan, even though the captopril provided effective blood pressure control. What is the most likely reason for discontinuing the captopril? A. Sexual dysfunction B. Blurred vision C. Rash and itching D. Dry cough

D Captopril (Capoten) is an ACE inhibitor used to control blood pressure. Some common side effects include rash, itching and blurred vision. Like many antihypertensives, ACE inhibitors can cause impotence. But a chronic cough is one of the most common and disturbing problems for clients using ACE inhibitors, prompting a change in blood pressure medication. Even after discontinuing the ACE inhibitor, it may take weeks or months for the cough to go away. Angiotensin receptor blockers, such as losartan (Cozaar), are often prescribed when clients cannot tolerate an ACE inhibitor.

At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being evaluated for cerebral palsy (CP). Which information provided by the parents would support this diagnosis? A. "Our child isn't talking yet." B. "We think our child seems smaller than other babies this age." C. "Mealtime is so messy when he tries to feed himself." D. "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg."

D Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity, infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born prematurely, it would be expected that he would be smaller than other babies. At this age, most children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy.

The nurse is planning care for a client with a cerebral vascular accident (CVA). Which approach would be most effective in the prevention of skin breakdown? A. Place client in the wheelchair for four hours daily B. Pad the bony prominences C. Massage reddened bony prominence D. Reposition every two hours when in bed

D Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained. If the client is in a wheelchair, a shift of the weight should be done every hour. Massage of reddened bony prominences is no longer recommended as a result of evidence-based research.

A nurse consistently ignores the call lights of clients who practice alternative lifestyles. The nurse's behavior is an example of what approach? A. Stereotyping B. Cultural insensitivity C. Prejudice D. Discrimination

D Discrimination is the differential treatment of individuals because they belong to a minority group. This generally refers to the limiting of opportunities, choices, or life experiences because of prejudices against individuals, cultures or social groups.

The nurse is reviewing the list of medications for a client who is scheduled for electroconvulsive therapy (ECT). Which medication does the nurse recognize as the one that will promote skeletal muscle relaxation? A. Methohexital (Brevital) B. Propofol (Diprivan) C. Atropine D. Succinylcholine (Anectine)

D ECT is performed under full general anesthesia and muscle relaxation. The sequence of administration is to give the anesthetic induction agent first, followed by the muscle relaxant. Two of the most commonly used anesthetics for this procedure are propofol and methohexital. These drugs are all well-suited for short procedures, such as ECT (which typically takes less than 10 minutes). Succinylcholine is the drug of choice for skeletal muscle relaxation in ECT, due to its brief duration of action. Atropine is an anticholinergic drug and may be used for ECT to help reduce the risk of arrhythmias and to minimize oral or other secretions and to prevent bronchial constriction.

The nurse is talking with the parents of a child who has recently been diagnosed with Hemophilia A. What should the nurse understand about the offspring of an unaffected father and a carrier mother? A. All sons will have the disease B. There is a 50% probability that a son will have the disease C. All daughters will be carriers D. There is a 25% probability that a daughter will be a carrier

D Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. When the carrier mother and the unaffected father are pregnant, there are four possible outcomes: 1. a 25% (one in four) chance of having a son without hemophilia 2. a 25% (one in four) chance of having a son with hemophilia 3. a 25% (one in four) chance of having a daughter who is a carrier 4. a 25% (one in four) chance of having a normal daughter who is not a carrier It may help to remember that the carrier woman only has one affected X chromosome, which is why there's only a 25% probability of a son having hemophilia. Notice that two of the response options have an absolute word in them ("all") - these types of statements are usually incorrect.

When taking the client's blood pressure (BP), a nurse cannot hear the sounds through the stethoscope. The nurse is able to palpate the systolic pressure reading. Which action should the nurse take first? A. Take the BP again in two minutes in the same arm B. Ask the client what the BP usually is C. Use an electronic BP cuff on the other arm D. Check to see if the stethoscope was turned to the bell side or is plugged in

D If a BP can be palpated for the systolic reading but nothing is heard on auscultation, the first action is to check to see if the stethoscope is turned to the bell side (a peripheral BP is taken using the diaphragm side of the stethoscope.) Then the nurse would wait two minutes between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two minute wait. The nurse should also be aware that the electronic cuff may not read pressures below 80 mm Hg.

A nurse administered intravenous immune globulin to an 18 month-old child with immune deficiency disorder. The parents asks why this medication is being given. How should the nurse respond? A. "This medication will improve your child's overall health status." B. "It will increase the effectiveness of the other medications your child receives." C. "It will slow down the replication of the virus." D. "This medication is used to prevent bacterial infections."

D Intravenous immune globulin is given to help prevent, as well as to fight, bacterial infections in young children with immune deficiency disorders. Immune globulin is made of antibodies from at least 1,000 donors to provide protection against a wide variety of infections.

A nurse notes sudden onset confusion in an 83 year-old client. Which recently ordered medication would have most likely contributed to this change? A. Cardiac glycoside B. Anticoagulant C. Liquid antacid D. Antihistamine

D Older adults are more susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at higher doses. The Beers Criteria lists this and other potentially inappropriate medications for the elderly (65 and older).

During the 1-month well-baby checkup, the parents respond to questions about their newborn. Which of the parents' comments is of greatest concern to the nurse? A. "The baby does not sleep for longer than two hours at a time." B. "We notice the baby is fussy and cries a lot." C. "The baby seems to want to eat every couple of hours." D. "When the baby spits up, it shoots across the room."

D Spit up that shoots across the room is indicative of projectile vomiting. Projectile vomiting, chronic hunger, poor weight gain, distended upper abdomen are clinical manifestation of pyloric stenosis. Hypertrophic pyloric stenosis (HPS) occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal. This produces an outlet obstruction and compensatory dilation, hypertrophy and hyperperistalsis of the stomach.This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after a feeding. Projectile vomiting may develop and the infant is fussy and hungry after vomiting. Infants with HPS have nonbilious vomiting in the early stages. Vomiting usually begins at 3 weeks of age but can start as early as 1 week and as late as 5 months. Vomiting usually occurs 30-60 minutes after feeding and becomes projectile as the obstruction progresses. Initially the infant is hungry and irritable, but prolonged vomiting may lead to dehydration, weight loss and failure to thrive.The other comments indicate normal behavior for a 1-month-old infant.

The nurse is caring for a child diagnosed with seizures. While teaching the family and the child about the medication phenytoin, what information should the nurse emphasize? A. Omit the medication if the child is seizure-free B. Serve a diet that is high in iron C. Administer acetaminophen to promote sleep D. Maintain good oral hygiene and dental care

D Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized. The medication should never be stopped, even if the child is seizure-free; sudden discontinuation could result in status epilepticus. Acetaminophen is not a sleep-aid and iron interferes with phenytoin absorption.

A client with possible hepatitis C discusses his health history with an admission nurse. The nurse should recognize which statement by the client as the most important in supporting this diagnosis? A. "I ate the best raw oysters last week." B. "I got back from Africa a few weeks ago." C. "I have had unprotected sexual contact with at least one person." D. "I had a blood transfusion in 1990."

D The client who received a blood transfusion prior to screening for hepatitis C (prior to July 1992) may show findings many years later, as often Hepatitis C is asymptomatic in its early stages. People who may be at risk for hepatitis C include those who have been on long-term kidney dialysis and have regular contact with blood at work. Having unprotected sexual contact with a person who has hepatitis C is less common, although the risk increases with multiple partners. Eating raw oysters would increase the risk of hepatitis A. Travel to Africa would increase the risk of exposure to malaria from mosquitoes carrying this disease, as well as HIV if the person were exposed to blood or had unprotected sex with someone who was HIV positive.

The nurse is caring for a 15 year-old client with a lengthy confining illness. This client is most at risk for altered psychoemotional growth and development due to what issue? A. Lack of trust B. Insecurity C. Loss of control D. Dependence

D The illness-client role fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness or withdrawal.

A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse should understand that a more frequent cause for suicide in adolescents is which factor? A. Feelings of anger or hostility with others B. Reunion wish or fantasy of the supernatural C. Progressive failure to adapt socially D. Feelings of alienation or isolation from peers

D The isolation from peers may occur gradually to result in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings to peers or family members. During adolescence, an important benchmark is to achieve a sense of identity and peer acceptance.

A nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 F (36.7 C) at 11:00 am. At 1:00 pm the child's parent reports that the child "feels very warm" to touch. What should the nurse do first? A. Administer the prescribed acetaminophen B. Reassure the parent that this is normal C. Offer the child cold oral fluids D. Reassess the child's temperature

D The nurse should listen to and show respect for what the parent is saying, because the parent is more sensitive to the variations in the child's condition. However, the nurse knows that a low-grade fever (99-101 F or 37.2-38.3 C) is common after surgery, which is why the nurse should first reassess the temperature before implementing any intervention. Usually the surgeon is contacted if the temperature is higher than 101.5 F (38.6 C).

In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize which approach? A. Eat smaller meals B. Limiting alcohol use C. Avoiding passive smoke D. Learning relaxation techniques

D The only factor that can enhance the client's response to pain medication for angina is reduction of anxiety through relaxation methods. Anxiety may increase intensity to a point where pain medication outcomes are totally ineffective.

The nurse works with children who have chronic conditions requiring frequent hospitalization and activity limitations. Which statement best describes the effects of immobility in children? A. Children are more susceptible than adults to the multisystem effects of immobility B. Immobility promotes independence and self-reliance in children C. Immobilized children quickly develop confusion and mental status changes D. The physical effects of immobility are similar in both children and adults

D The physical effects of immobility are similar for clients of almost any age. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, constipation, bone demineralization, and cardiopulmonary complications. Immobility can negatively impact self-image and having to rely on others to meet their basic needs, especially in adolescents. Planning and providing nursing care in creative ways, and involving children in their care, and providing age-appropriate diversion can help reduce the effects of immobility. Older adults with chronic conditions are at greatest risk for developing confusion.

The nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? A. The policies and procedures of the assigned agency in that state B. With a nurse colleague who has worked in that state two years ago C. The American Nurses Association's Social Policy Statement D. The state nurse practice act in which the assignment is made

D The state Nurse Practice Act is the governing document of the scope of practice in any given state.

A 48-year-old female client with metastatic breast cancer is scheduled to receive her first dose of a trastuzumab (Herceptin). Which of the following results would prompt the nurse to hold the prescribed treatment and discuss the assessment with the ordering health care provider? A. Positive human epidermal growth factor receptor 2 (HER2) B. Positive lymph node involvement C. Blood glucose 130 mg/dL (7.22 mmol/L) D. Irregular apical pulse

D Trastuzumab is a monoclonal antibody used as anticancer therapy for women with HER2-positive breast cancer. The main concern in administering trastuzumab is cardiotoxicity and it is used with caution in any client who has a pre-existing heart condition. An ejection fraction is obtained as a baseline before treatment and may be monitored every few months while the client is receiving this medication. Although the blood glucose result is high-normal, it would have no impact on the administration of this drug.