Question Trainer 6 Remediation

Which behavior by the client should the nurse record to indicate that the client is experiencing hallucinations? 1. The client sits immobilized for long periods of time. 2. The client turns and tilts his head as if talking to someone. 3. The client expresses the belief that the health care provider is out to get him. 4. The client wrings his hands and paces constantly.

(1) describes behavior associated with depression (2) correct—hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety

The RN cares for the client just admitted after sustaining a second-degree thermal injury to the right arm. Which observation is MOST important to report to the health care provider? 1. Pain around the periphery of the injury. 2. Gastric pH less than 5.0. 3. Increased edema of the right arm. 4. An elevated hematocrit.

(1) expected findings in burn wound resolution (2) correct—client is at risk for Curling's ulcer which may develop 24 hours after a severe burn injury; gastric pH acidic (1-5) (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution

The nurse plans discharge for a group of clients. The nurse identifies which clients require a referral for home care? Select all that apply. 1. A postoperative appendectomy client who reports incisional pain. 2. A newly diagnosed diabetic client who has a vision impairment .3. A postoperative cholecystectomy that requires steps to get into their apartment. 4. A client with congestive heart failure who underwent diuresis in the hospital. 5. An elderly client with a new right hip replacement who lives with a daughter.

(1) expected outcome, treat with analgesics (2) correct—Follow up on medication administration and ability for self care at home. (3) teach client to limit trips up and down and take stairs slowly (4) correct—assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia (5) correct—the client will need assessment in the home for self care; family can help but not full care.

The nurse cares for the client reporting moderate pain. Which nursing action is MOST important to provide the client with effective pain relief? 1. Teach the client about the pain. 2. Establish a trusting relationship with the client. 3. Determine how various relaxation techniques affect the pain. 4. Provide alternative measures to relieve pain.

(1) not most important (2) correct—necessary to work with client to identify interventions to relieve pain (3) part of the evaluation phase (4) only a portion of interventions used to relieve pain

The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOST concerned if a family member makes which statement? 1. "We will be able to leave our baby for brief periods of time." 2. "We plan to sleep by our baby's crib." 3. "We can remove the monitor during our baby's bath." 4. "A family member will closely watch the monitor all the time."

1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct—indicates a feeling that monitor may not let them know if their infant stops breathing

The home care nurse visits a client receiving levothyroxine sodium 0.1 mg PO daily. Which finding indicates to the nurse that the client is getting favorable results from the medication? 1. Decreased blood pressure. 2. Increased urine output. 3. Decreased pulse rate. 4. Increased respiratory rate.

1) characteristic of hypothyroidism, would indicate that medication is not working (2) correct—medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted (3) characteristic of hypothyroidism, would indicate that medication is not working (4) respiratory rate may or may not be affected by medication

The triage nurse for the women's health center receives 4 phone messages. In which order should the nurse return the phone calls?

**location of pain is difference of 1 and 2 1. Multipara woman at 4 weeks gestation reporting unilateral, dull, abdominal pain needs to be evaluated for an ectopic pregnancy; Unstable, Unexpected, Circulatory, Real 2. Multipara woman at 6 weeks gestation reporting red vaginal bleeding and moderate cramps symptomatic of threatened abortion; Unstable, Unexpected, Circulation, Potential, moderate bleeding 3. The primigravida woman at 5 weeks gestation having light spotting and mild cramping symptoms of spontaneous abortion; Unstable, Unexpected, circulation, potential light spotting. 4. The primigravida woman at 7 weeks gestation reporting whitish vaginal secretions - expect during first trimester of pregnancy

The nurse observes the student nurse perform a moist-to-dry dressing change on the client's 2-inch incision. In which order does the student perform the procedure?

1. Gently free dressing 1) should be removed dry so that wound debris and necrotic tissue are removed with old dressing 2. Dry skin surrounding the wound 2) exposed skin around the wound is cleaned and dried 3.Moisten gauze 3) because this is a moist-to-dry dressing, the first clean layer of gauze is moistened with prescribed amount of prescribed solution 4. apply moist gauze as single layer 4) moist gauze is applied in a single layer 5. Cover with dry dressing 5) dry gauze is then applied

The nurse knows which action is a priority for the infant with a positive PKU blood test? 1. Place the infant on Lofenalac formula. 2. Administer medium-chain triglyceride (MCT) oil with each feeding. 3. Provide genetic counseling for the family. 4. Place the infant on Lorenzo's Oil treatments.

(1) CORRECT—Guthrie blood test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine but contains minerals and vitamins to provide a balanced nutritional formula (2) fat source found in some formulas (3) important but is not as high a priority as providing Lofenalac formula (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)

The health care provider prescribes sucralfate 1 gm PO tid and 2 Magnesium hydroxide/Aluminum hydroxide tablets tid for the client in the outpatient clinic. The client asks the nurse when to take these medications. Which instruction by the nurse is BEST? 1. Take the sucralfate and the Magnesium hydroxide/Aluminum hydroxide 1 hour ac. 2. Take the Magnesium hydroxide/Aluminum hydroxide 1 hour ac and the Carafate 1 hour pc. 3. Take the sucralfate and the Magnesium hydroxide/Aluminum hydroxide 2 hours pc and hs. 4. Take the sucralfate 1 hour ac and the Magnesium hydroxide/Aluminum hydroxide 1 hour pc.

(1) Magnesium hydroxide/Aluminum hydroxide (antacid) decreases bonding to gastrointestinal mucosa, so don't give within 30 minutes of each other (2) sucralfate best results on empty stomach; antacids decrease bonding to gastrointestinal mucosa, so don't give within 30 minutes of each other (3) antacids decrease bonding to gastrointestinal mucosa, so don't give within 30 minutes of each other (4) correct—sucralfate has best results on empty stomach

The client receives digoxin 0.25 mg PO qd and furosemide 40 mg PO bid. The client calls the health care provider (HCP) reporting mild diarrhea. The HCP prescribes bismuth subsalicylate 60 mg after each bowel movement for two days and instructs the client to call back if symptoms don't subside. The client asks the office nurse if there should be any changes to the medication schedule. The nurse should instruct the client to take which action? 1. Continue the medication schedule. 2. Wait 1 hour before taking the scheduled medications if the bismuth subsalicylate is taken. 3. Hold the scheduled medications until the diarrhea subsides. 4. Take the digoxin but hold the furosemide if the client takes the bismuth subsalicylate.

(1) PO meds would be absorbed by bismuth subsalicylate, not by stomach (2) correct—bismuth subsalicylate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later

Which finding indicates to the nurse that the client's Salem sump tube (nasogastric) is functioning effectively? 1. Fluctuation of the fluid level in the water seal chamber. 2. Active bubbling in the suction bottle. 3. The presence of a hissing sound from the blue lumen tube. 4. A pressure of 25 mm Hg in the esophageal balloon.

(1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct—hissing sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube

The female client is diagnosed with human papillomavirus (HPV). Which client statement, if made to the nurse, illustrates an understanding of the possible sequelae of this illness? 1. "I will need to take antibiotics for at least a week." 2. "I will use only prescribed douches to avoid a recurrence." 3. "I will return for a Pap smear in six months." 4. "I will avoid using tampons for eight weeks."

(1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct—several strains of HPV are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome

The nurse cares for the young adult client. The client is scheduled for the first debridement of a deep partial thickness burn of the left arm. It is MOST important for the nurse to take which action? 1. Assemble all necessary supplies and medications. 2. Plan adequate time for the dressing change and provide emotional support. 3. Prepare the client and family for the pain the client will experience during and after the procedure. 4. Limit visitation prior to the procedure to reduce stress.

(1) appropriate but is not a high priority (2) correct—planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure but also on providing the emotional support necessary for the client (3) appropriate but is not a high priority (4) appropriate but is not a high priority

The nurse sees the client with a 25-year history of alcohol abuse in the outpatient clinic. The client is being treated for chronic cirrhosis. Which symptom suggests to the nurse that the client is in the early stages of hepatic encephalopathy? Select all that apply. 1. The client has a distended abdomen and protruding umbilicus .2. The client has difficulty describing what he does at work. 3. The client states difficulty sleeping through the night. 4. The client's exhibits asterixis when hands are assessed. 5. The client sleeps 10-12 hours through the day. 6. The client's spouse notes a change in the client's handwriting.

(1) ascites is symptom of cirrhosis (2) correct—impaired thought processes is early symptom (3) correct—insomnia and sleep disturbances are signs of grade 0 (4) flapping of the hands after extension is grade 3 and above; is late symptom (5) lethargy and extended sleep patterns are signs of grade 3; late signs (6) correct—Writing changes and hand tremors are grade 0; early signs

After the client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which action? 1. Monitor vital signs every four hours 2. Observe for frequent swallowing .3. Monitor for signs of respiratory distress every hour. 4. Position the client in the supine position.

(1) assessment is not specific to this surgery (2) assessment; method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct—assessment; after surgery, swelling can occur, which causes respiratory distress (4) implementation; head of the bed should be elevated

The client comes to the nurse's station for their prescribed antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes. Which action should the nurse take FIRST? 1. Determine what other medications the client is taking. 2. Perform a neurological assessment. 3. Administer haloperidol decanoate IM stat. 4. Administer the PRN trihexyphenidyl IM immediately.

(1) assessment; demonstrating acute extrapyramidal side effects (2) assessment; no validation required (3) haloperidol is antipsychotic, will exacerbate symptoms (4) correct—administer benztropine or trihexyphenidyl

Butorphanol tartrate 1 mg IM is ordered for the woman 1 day postpartum. Which action is MOST important for the nurse to take after administering the medication? 1. Observe the woman for sedation. 2. Monitor the vital signs. 3. Assess for visual disturbances. 4. Evaluate fluid status.

(1) causes sedation but not most important (2) correct—decreases rate and depth of respirations (3) diplopia and blurred vision are side effects but not most important (4) not side effect of medication

The nurse cares for the client diagnosed with a perforated bowel secondary to a bowel obstruction. At the time the diagnosis is made, which should be the priority in the nursing care plan? 1. Maintain the client in a supine position. 2. Notify the client's next of kin. 3. Prepare the client for emergency surgery. 4. Remove the nasogastric tube.

(1) client is kept in semi-Fowler's position (2) not a priority action (3) correct—when the bowel perforates as a result of increased intraluminal pressure within the gut, intestinal contents are released into the peritoneum, leading to peritonitis (4) should not be done

The nurse cares for a client diagnosed with hyperthyroidism. Which action, if taken by the nurse, is BEST? 1. Provide the client with extra blankets. 2. Instill artificial tears PRN. 3. Offer the client reading material. 4. Offer frequent low-calorie snacks.

(1) client is usually sensitive to heat (2) correct—clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie

The nurse determines teaching is effective if the parents of the 4-year-old child diagnosed with sickle cell anemia makes which statement? Select all that apply. 1. "When my daughter reports pain, I use cold compresses." 2. "I try to keep my daughter away from people with infections." 3. "I sometimes have to give my daughter some of her morphine for pain." 4. "I encourage my daughter to drink a lot of water." 5. "I love to watch my daughter play hard through a whole soccer game."

(1) cold will cause vasoconstriction limiting blood flow (2) correct— important for a sickle cell client to prevent sickling crisis (3) correct—reflects appropriate use of medication to decrease the client's pain (4) correct—important for a sickle cell client to prevent sickling crisis (5) frequent rest periods are necessary to prevent deoxygenation with can precipitate a crisis.

The nurse leads a class for expectant mothers. Which comment indicates to the nurse that the pregnant woman understands the recommended dietary caloric increase for pregnancy? 1. "I will need to double my calorie intake because I am now eating for two." 2. "I can add an additional 500 calories by drinking milkshakes." 3. "I need to add 300 calories by increasing my intake of the basic food groups." 4. "I really need to watch my calorie intake so that I will not gain too much weight."

(1) common misconception (2) 500 calories is too many calories, and a milkshake is not a good food source because of its fat content (3) correct—recommended to increase calorie intake by 300 for fetal growth, maternal tissues, and the placenta (4) unsafe for the pregnant client

The clinic nurse is giving instructions to the family of a school-aged child diagnosed two weeks ago with hepatitis A. The family asks if the child can return to school. Which response by the nurse is BEST? 1. "You must isolate your child at home for two more weeks." 2. "Why don't you speak with the health care provider about this matter?" 3. "Your child may return to school this week." 4. "Your child may return to school in two weeks but cannot participate in sports."

(1) communicable for two to three weeks before onset of jaundice and about 1 week after onset of jaundice (2) passing the buck (3) correct—type A hepatitis is not infectious within a week or so after the onset of jaundice; child can return to school (4) can return to school, activity at that time depends on the child's energy level

The nurse answers the phone on the psychiatric unit. The caller identifies himself as the spouse of a client and inquires about the client's condition. Which response by the nurse is MOST appropriate? 1. "I cannot deny or confirm any client's presence in this hospital." 2. "Clients are not allowed access to this phone. Please call the number you were given." 3. "I cannot give information over the phone. If you come in, we can discuss her condition." 4. "I will have to ask her if she wishes for me to give out that information."

(1) confidentiality prohibits a professional from discussing information about the client (2) correct— psychiatric client retains civil rights to communicate with outside world and have reasonable access to telephones; unless client opts out of the registry, their location may be given out with prearranged codes (3) breaks confidentiality (4) client able to speak for herself

While doing a physical examination of a 1-year-old child, which assessment should be completed by the nurse LAST? 1. Examine infant's ears .2. Auscultate the breath sounds. 3. Auscultate the apical heart rate. 4. Evaluate motor functions.

(1) correct—all invasive procedures (eyes, ears, mouth) should be done last, so as not to alter cardiopulmonary assessment of the child (2) auscultate while child is quiet (3) auscultate heart, lungs, abdomen, and then palpate and percuss (4) elicit reflexes as body part examined

The nurse prepares the client for a skin biopsy. Which client statement should the nurse report to the health care provider? Select all that apply. 1. "I've been taking aspirin for my sore knees." 2. "Using lotion has helped my dry skin." 3. "I have a tanning appointment tomorrow." 4. "I had a big breakfast this morning." 5. "I have changed my mind about having this done."

(1) correct—aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure (2) does not affect the accuracy or results of the biopsy even though it is not recommended (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy (5) correct—The client is free to change their mind but the health care provider needs to be informed.

The health care provider writes an order for piperacillin 3 g IV q6h for the adult client. Before administering this drug, the nurse should take which action appropriate to this medication? Select all that apply. 1. Check for known allergies to medications. 2. Obtain specimen for culture and sensitivity 3. Administer dexamethasone sodium phosphate 2 mg IV stat. 4. Obtain client's current creatinine clearance results. 5. Ensure that the client's respiratory rate is over 12. 6. Check the client's blood pressure both sitting and standing

(1) correct—assessment; piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) correct—assessment; must be completed prior to starting the antibiotic. (3) implementation; not relevant for administration of this medication (4) correct—assessment; creatinine clearance values necessary to determine appropriate dosage ordered. (5) assessment; not required for this classification of medication. (6) assessment; not required for this classification of medication.

The nurse cares for clients in the outpatient clinic. The young adult female arrives for help with weight loss. The client's weight is 257 pounds, and the client is 5'7". Which diet choice indicates the MOST appropriate choice for breakfast? 1. Applesauce, cream of wheat, toast. 2. Scrambled eggs and toast, one slice of bacon. 3. One glass of grapefruit juice. 4. Bagel with two ounces of cream cheese and a banana.

(1) correct—breakfast with some substance, won't leave client feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content

The nurse instructs the parents of the child diagnosed with celiac disease. The nurse determines teaching is effective when the parents make which statement? Select all that apply. 1. "My child's diet should be high in calories." 2. "I will make sure I serve my child foods high in protein." 3. "I will make a nice oatmeal breakfast twice a week." 4. "I will pack raw carrots or celery for snack every day." 5. "I will use wheat bread for sandwiches"

(1) correct—celiac disease is characterized by an intolerance for gluten; foods containing rye,oats, wheat, and barley should be restricted (2) correct—celiac disease is characterized by an intolerance for gluten; foods containing rye, oats, wheat,and barley should be restricted (3) does not reflect appropriate dietary needs for this child (4) does not reflect appropriate dietary needs for this child (5) does not reflect appropriate dietary needs for this child

The nurse performs discharge teaching for the client diagnosed with multiple sclerosis. It is MOST important for the nurse to include which instruction? Select all that apply. 1. Ambulate as tolerated every day. 2. Avoid overexposure to heat or cold. 3. Perform stretching and strengthening exercises. 4. Participate in social activities. 5. Use cold packs on joints.

(1) correct—client is encouraged to ambulate as tolerated (2) correct—overexposure to heat or cold may cause damage related to the changes in sensation (3) correct—client is encouraged to participate in an exercise program to include range-of-motion (ROM), stretching, and strengthening exercises (4) correct—client is encouraged to continue usual activities as much as possible, including social activities (5) overexposure to heat or cold may cause damage related to the changes in sensation

When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which action should the nurse take FIRST? 1. Cover the open area with sterile gauze soaked in normal saline. 2. Reapply a sterile dressing after cleaning the incision with hydrogen peroxide. 3. Pack the opened area with sterile 0.75-inch gauze soaked in normal saline. 4. Apply Neosporin ointment and cover the incision with Tegaderm dressing.

(1) correct—evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of health care provider (2) wounds are not cleansed with peroxide (3) there is not an order to pack the wound (4) not a sterile procedure

The RN cares for the 4-year-old diagnosed with epiglottitis. Which observation indicates to the nurse that the child is experiencing an early complication of hypoxemia? Select all that apply. 1. Heart rate of 148 beats per minute (bpm). 2. Bluish discoloration of the skin. 3. Bluish discoloration around the mouth. 4. Throwing toys and kicking the bed. 5. Difficulty swallowing. 6. Nasal flaring with activity.

(1) correct—heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) correct—Irritability is an early sign of hypoxemia. temper tantrum like behavior is not expected in a 4 year old. (5) sign of epiglottitis not hypoxemia (6) correct—Nasal flaring is an early sign of hypoxemia.

A staff member informs the nurse that the staff member's 6-year-old child has head lice. It is MOST important for the nurse to take which action? 1. Inspect the staff member's head for louse and nits. 2. Inform the staff member that he cannot care for clients until further notice. 3. Request that the staff member contact his health care provider. 4. Instruct the staff member about how to use Kwell.

(1) correct—observe for movement (louse) or small whitish oval specks that adhere to the hair shaft (nits); treat with gamma-benzene hexachloride (Kwell) (2) confirm the presence of lice before excluding from duty; if lice present, exclude from client care until appropriate treatment has been received and shown to be effective (3) should assess first (4) should assess first, apply shampoo to dry hair and work into lather for four to five minutes

The adult client comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back. The nurse should instruct the client to take which action? 1. Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing. 2. Soak in a warm tub twice a day, and rub the areas with a washcloth before covering them. 3. Shower daily using a mild antimicrobial soap from a pump dispenser, and leave the lesions uncovered. 4. Clean the lesions twice a day with a diluted solution of povidone-iodine, and leave them open to the air.

(1) correct—open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered because of open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma

The nurse plans discharge for the client post mild myocardial infarction (MI). The client smokes one pack of cigarettes per day. Which recommendation by the nurse is BEST? 1. Participate in a program such as nicotine avoidance. 2. Avoid aerobic physical activity. 3. Install a humidifier in the home heating system .4. Strict adherence to a low-calorie, low-sodium, high-lipid diet.

(1) correct—smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet

The nurse instructs the prenatal client about the importance of prenatal vitamins. It is MOST important for the nurse to include which instruction? 1. "Take prenatal vitamins with orange juice at bedtime." 2. "Take the prenatal vitamins at breakfast with coffee." 3. "Take the prenatal vitamins with milk at lunch." 4. "Take the prenatal vitamins with water at dinner."

(1) correct—taking the vitamins with something acidic increases the absorption of iron; taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep (2) not the best way to take prenatal vitamins (3) not the best way to take prenatal vitamins (4) not the best way to take prenatal vitamins

The clinic nurse obtains a throat culture from the client diagnosed with pharyngitis. It is MOST important for the nurse to take which action? 1. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx. 2. Obtain a sputum container for the client to use. 3. Irrigate with warm saline, and then swab the pharynx. 4. Hyperextend the client's head and neck for the procedure.

(1) correct—tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended

The nurse cares for the client with deep partial thickness and full thickness burns. The client receives morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention. Which action, if taken by the nurse, is BEST? 1. Recommend that the morphine dose be decreased. 2. Withhold the pain medication. 3. Administer the medication by another route. 4. Explore alternative pain management techniques.

(1) could indicate a possible impending ileus; this option is not ideal (2) inappropriate (3) inappropriate (4) correct—morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important

The nurse supervises a student nurse obtaining an infant's vital signs. Which action should the student nurse complete FIRST? 1. Obtain the infant's temperature. 2. Count respirations for 15 seconds and multiply the number by 4. 3. Count respirations for a minute prior to arousing the infant. 4. Use a stethoscope with a 1.5-inch diaphragm to count the apical pulse.

(1) count respirations for 1 full minute before taking temperature (2) should count for a full minute (3) correct—respirations should be counted for 1 full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations

Following total hip arthroplasty, an elderly client is ordered to begin ambulation with a walker. Which statement by the nurse is correct? Select all that apply. 1. "Sit in a low chair for ease in getting up to use the walker." 2. "Make sure rubber caps are in place on all four legs of the walker." 3. "You will begin weight bearing on the affected hip soon." 4. "Have someone help you tie your shoes before you begin ambulating." 5. "Your walker is the correct height when your elbows bend at a 50° angle." 6. "Always wear non skid footwear when you walk."

(1) full weight bearing or flexion of the hip greater than 90° should be avoided to prevent dislocation of prosthesis (2) correct—intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided to prevent dislocation of prosthesis (4) correct—flexion of the hip greater than 90° should be avoided (5) If the walker is the correct height the elbows should be at a 30° angle. (6) correct—Non skip footwear is a safety consideration and should always be worn with ambulation.

The RN obtains a urinalysis from the client reporting dysuria, urinary frequency, and discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based on which finding? 1. Negative glucose. 2. RBCs present. 3. No WBCs or RBCs reported. 4. Specific gravity 1.018.

(1) glucose increases during the inflammation process; it is not a primary component in determining urinary tract infections (2) not as complete a response as answer choice 3 (3) correct—with the client's symptoms, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine

The nurse instructs a client about how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor. Which action, if performed by the client, indicates to the nurse the need for further teaching? 1. The client dangles the hand before sticking the finger with the lancet. 2. The client sticks the finger on the side of the distal phalanx. 3. The client touches the strip with a large drop of blood hanging from the fingertip. 4. The client milks the finger after sticking it.

(1) helps facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct—forces interstitial fluid to mix with capillary blood and dilutes the blood

The nurse cares for the 17-year-old married male scheduled for a hernia repair. The nurse administers fentanyl 100 mcg with hydroxyzine pamoate 25 mg IM. Thirty minutes later the nurse discovers that the informed consent is unsigned. Which action by the nurse is best? 1. Cancel the surgery. 2. Ask the client to sign the informed consent. 3. Notify the health care provider. 4. Ask the client's mother to sign the informed consent.

(1) inappropriate action; should inform health care provider (2) can't sign informed consent if client has been drinking alcohol or has been pre-medicated for surgery (3) correct—health care provider needs to be informed (4) married minor is considered emancipated; provides own consent for treatment

The nurse reviews charts on a medical/surgical unit. The nurse identifies which example is a properly recorded client chief complaint in a nursing health history? 1. "Complains of midepigastric discomfort with flatus after meals." 2. "Area above umbilicus appears to be painful and tender to palpation." 3. "My stomach hurts after dinner every night." 4. "Rebound tenderness present in mid- to upper-abdominal area."

(1) incorrectly stated (2) objective finding (3) correct—chief complaint should be recorded using the client's own words (4) objective finding

In planning care for a client with signs of increased intracranial pressure (ICP), the nurse should include which implementation? 1. Encourage coughing and deep breathing to prevent pneumonia. 2. Suction the airway every two hours to remove secretions. 3. Position the client in the prone position to promote venous return .4. Determine cough reflex and ability to swallow prior to administering PO fluids.

(1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15-30° to promote venous drainage (4) correct—assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration

The home health nurse makes a follow-up visit for the elderly client receiving isoniazid 200 mg every day for six months. The nurse is most concerned if the client makes which statement? 1. "I have blurred vision at times." 2. "My legs and knees hurt." 3. "My hands and feet tingle." 4. "I think I had a migraine yesterday."

(1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct—may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication

The toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate and dimercaprol. Which nursing action has the highest PRIORITY? 1. Keep a tongue blade at the bedside. 2. Encourage the child to participate in play therapy. 3. Apply cool soaks to the injection site. 4. Rotate the injection sites.

(1) no longer used for seizures, but it is important to have seizure precautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct—highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites

The nurse cares for the client currently hospitalized with chronic kidney disease. The client has 3+ pitting edema of the lower extremities. Which nursing observation indicates a therapeutic response to therapy for the edema? Select all that apply. 1. Serum potassium 4.0 mEq/L (4.0 mmol/L). 2. Plasma glucose 140 mg/dL (7.8 mmol/L). 3. Increased specific gravity of the urine. 4. Weight loss of 5 lb over last two days. 5. Decrease in calf circumference by 2 cm.

(1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct—edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective (5) correct—edema is a result of sodium and fluid retention; decrease in peripheral circumference should occur if therapy is effective

The nurse administers sublingual nitroglycerin to the client reporting chest pain. Which observation is MOST important for the nurse to report to the next shift? 1. The client indicates the need to use the bathroom. 2. Blood pressure has decreased from 140/80 to 90/60. 3. Respiratory rate has increased from 16 to 24. 4. The client indicates that the chest pain has subsided.

(1) not a side effect of this medication (2) correct—hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome

A college student reports a history of a motor vehicle accident six months ago. The client was minimally injured but a friend was killed. The client comes to Student Health Services reporting inability to study or sleep. The client also reports thinking they are "going crazy." Which action by the nurse is MOST important? 1. Perform a complete physical and social history. 2. Obtain a complete drug and alcohol history, including reports from a drug screen. 3. Review the significant events of the last year. 4. Explore the client's coping methods over the crash and the friend's death.

(1) not most important initially (2) not most important initially (3) not most important initially (4) correct—situational crisis; priority is to determine how client coped with crisis in the past and build on client's coping strategies

The client is scheduled for a traditional abdominal cholecystectomy. Which statement, if made by the nurse to the client the night before surgery, is MOST important? 1. "It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet." 2. "Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times." 3. "There will be a machine available to you after surgery for you to use to continuously receive pain medication." 4. "You may come back from surgery with a tube in your nose that drains your gallbladder."

(1) not most important initially, teaching should be done before discharge (2) correct—should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication administered intermittently (4) NG tube used to drain stomach, T tube used to drain common bile duct

During the first 24 hours after parenteral nutrition (PN) therapy is started, the nurse should take which action? 1. Monitor vital signs every two hours. 2. Determine urinalysis results. 3. Evaluate blood glucose levels. 4. Compare weight with the previous readings.

(1) not necessary to do every 2 hours; every 4 hours is appropriate action (2) important but not the priority (3) correct— parenteral nutrition (PN), or hyperalimentation, has a high glucose content; important to monitor glucose levels (4) appropriate but not a priority

The client diagnosed with lung cancer undergoes a pneumonectomy. In the immediate postoperative period, which assessment is MOST important? 1. Presence of breath sounds bilaterally. 2. Position of the trachea in the sternal notch. 3. Amount and consistency of sputum. 4. Increase in the pulse pressure.

(1) on the surgical side, breath sounds will be absent (2) correct—position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation

The nurse performs discharge teaching for a client receiving fluticasone by inhalation. Which statement by the client indicates that the teaching was successful? 1. "I will use fluticasone when I feel an asthma attack beginning." 2. "I use my albuterol inhaler after I inhale the fluticasone." 3. "The medication will prevent infection in my leg." 4. "I will rinse my mouth every time after I inhale the fluticasone."

(1) outcome not desired; fluticasone should be used on a regular basis; is not effective during acute asthmatic episodes. (2) outcome not desired; bronchodilator medication should be used prior to anti-inflammatory medication to increase amount of anti-inflammatory medication inhaled (3) outcome not desired; is an inhaled glucocorticoid and anti-inflammatory; is not used to treat infection (4) correct—outcome desired; rinsing or gargling after use of an inhaled glucocorticoid will decrease the risk of candida infection

The client, gravida 2/para 1, is admitted for induction of labor with oxytocin. It is MOST important for the nurse to take which action? 1. Mix oxytocin in D5W, begin at 5 mg/ml as primary IV to gravity flow. 2. Decrease the rate/flow of oxytocin if the fetal heart rate is below 150. 3. Piggyback the oxytocin into the mainline IV, and maintain the flow by gravity. 4. Start an IV line, and piggyback the oxytocin with an infusion pump.

(1) oxytocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct—oxytocin should always be a secondary infusion controlled by an IV pump

The nurse observes a new graduate nurse palpating the uterine contractions of a primipara in active labor. Which action, if taken by the new graduate nurse, is appropriate? 1. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen. 2. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly. 3. The graduate nurse places one hand on the abdomen over the fundus, and with the fingertips, presses gently. 4. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.

(1) palpations should be done with fingertips, not palms of hands (2) palpations should be done with fingertips, not heels of hands (3) correct—done with fingertips (4) palpations should be done with fingertips, not palms of hands

The nurse instructs the client with newly diagnosed type 1 diabetes about proper foot care. Which statement, if made by the client to the nurse, indicates that further teaching is necessary? Select all that apply. 1. "I should cut my toenails straight across." 2. "I love to go barefoot." 3. "I should inspect my feet once a week." 4. "I should bathe my feet daily in warm water." 5. "I can keep using my heating pad on my feet." 6. "I am going to buy some warm socks."

(1) prevents ingrown nails (2) correct—feet should be protected by footwear (3) correct—should inspect feet daily for blisters, sores, ingrown nails, and cuts (4) proper care (5) correct—extremes of temperature are dangerous for the diabetic foot. (6) Keeping the feet warm is a correct action.

The nurse cares for the client with a marked depression of T cells. The nurse should take which action? 1. Keep a linen hamper immediately outside the room. 2. Restrict eating utensils to spoons made of plastic. 3. Provide masks for anyone entering the room. 4. Remove any standing water left in containers or equipment.

(1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct—water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium

he nurse cares for the 8-month-old client. Which observation tells the nurse the client is in pain? Select all that apply. 1. Decreased pulse rate. 2. Increased fluid intake. 3. Decreased respiratory rate. 4. Rubbing a body part and crying .5. Eyes closed tightly. 6. Pushes away painful nurses hands.

(1) pulse rate would increase (2) nonspecific regarding pain (3) does not reflect pain (4) correct—because an infant cannot talk, nurse needs to be aware of nonverbal signs of pain, such as rubbing the ear because of an earache (5) correct—Facial expression are used by the young infant. brows lowered and mouth opened are others (6) This is something a young child would do not a 8 month old.

The client at 39 weeks gestation in active labor screams, "I have to push, I have to push." The nurse notes that the client is 8 cm dilated. The nurse should take which action? 1. Instruct the client to take a deep breath and bear down. 2. Apply gentle but firm pressure to the client's abdomen. 3. Coach the client in relaxation techniques. 4. Tell the client to pant with pursed lips.

(1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct—describes transition phase of labor, breathing technique allows client to control pain and urge to push and promotes adequate oxygenation of fetus

The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a mask. The nurse determines that the precautions are correct if the student nurse is caring for which client? 1. An infant diagnosed with respiratory syncytial virus. 2. A young child with a wound infected with S. aureus 3. A teenager diagnosed with toxic shock syndrome. 4. A teenager diagnosed with rubella (German measles).

(1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct—droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open

The nurse performs a routine IV tubing change on a client with a central line. Fifteen minutes later, the nurse re-enters the client's room to find the client cyanotic, short of breath, and reporting of pain. The client's vital signs are BP 84/62, pulse 112, respirations 18. What is the FIRSTaction the nurse should take? 1. Call the health care provider to report the client's symptoms. 2. Lower the head of the bed and place the client on the left side. 3. Place the client in high Fowler's position. 4. Start oxygen at 4 L/minute via nasal cannula.

(1) second action, first should respond to potential problem of emboli (2) correct—air will rise to right atrium, minimizes chance of air bubbles entering pulmonary circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action

The nursing assistive personnel comes to take the client by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck. Which observation, if made by the nurse, requires an intervention? 1. The client removes her dentures and gives them to her spouse. 2. The client's vital signs are BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C). 3. The client has a nitroglycerine patch on the right chest area. 4. The client has red nail polish on both fingers and toes.

(1) should be removed before the test (2) results are within normal limits (3) correct—should be removed before the test; transdermal patch contains heat-conducting aluminized layerand burning of skin may occur (4) unnecessary to check capillary refill

The nurse cares for the client diagnosed with hyperparathyroidism. Which symptom is most important for the nurse to report to the next shift? 1. Abdominal discomfort. 2. Hematuria. 3. Muscle weakness. 4. Diaphoresis.

(1) sign of hyperparathyroidism but does not require reporting (2) correct—hematuria is a sign of urinary tract calculi; 55% of hyperparathyroid clients have urinary tract calculi (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting

A client is scheduled for a cardiac catheterization at 0800. The client's laboratory work was completed five days ago, and the results include K+ 3.0 mEq/L (3.0 mmol/L), Na+ 148 mEq/L (148 mmol/L), glucose 178 mg/dL (9.9mmol/L). The client reports of muscle weakness and cramps. Which action by the nurse is BEST? 1. Administer the 0700 dose of spironolactone. 2. Encourage eating bananas for breakfast. 3. Obtain stat K+ level. 4. Call for 12-lead EKG.

(1) spironolactone is potassium-sparing diuretic and is an oral medication, client is NPO for procedure (2) is not feasible prior to the cardiac cath because the client is NPO (3) correct—signs and symptoms are indicative of hypokalemia; stat serum K+ level is needed to confirm the K+ level prior to going for cardiac catheterization (4) is unnecessary at this time

The nurse cares for the client with rheumatoid arthritis. The nurse prepares for the client to be discharged. The nurse knows that for the client to manage at home alone the client needs to be able to perform which activity? Select all that apply. 1. Climb up stairs. 2. Lace shoes. 3. Comb hair. 4. Walk without assistance. 5. Brush teeth 6. Eat independently

(1) stairs can be eliminated in the client's environment (2) is a modifiable problem with the use of slip-on shoes (3) correct—is part of basic hygiene and grooming that must be done daily to maintain overall health (4) is not necessary for independence; walker or wheelchair may be used (5) correct—is part of basic hygiene and grooming that must be done daily to maintain overall health (6) correct—is part of basic ADLs that must be done daily to maintain overall health

A health care provider writes an order for an HIV-positive infant to receive IPV immunization. Which nursing action is most appropriate? 1. Wear gloves and a gown when administering the immunization. 2. Administer the immunization. 3. Contact the health care provider for clarification of the order. 4. Determine if child has a history of seizures.

(1) standard precautions required (2) correct—inactivated polio (IPV) appropriate; contraindications include anaphylactic reaction to neomycin, streptomycin, or polymyxin B (3) no reason to discuss with health care provider (4) if child had seizure within three days of DTP, evaluate whether risks of giving immunization outweigh the benefits

A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique? Select all that apply. 1. "I need to buy sterile gloves to redress this wound." 2. "I should wash my hands before redressing my wound." 3. "I should keep the wound covered at all times." 4. "I should only use whatever my health care provider orders for the dressing change." 5. "I should make sure someone looks at my wound every dressing change." 6. "I will throw the dressing away in the kitchen garbage wrapped in my glove."

(1) sterile gloves are not commonly ordered. There is no information in the question to suggest this level of dressing (2) correct—indicates understanding of asepsis, hallmark is hand washing (3) is not possible to carry out (4) correct—should use only the prescribed medications on the wound (5) correct—The wound should be observed for changes with every dressing change. (6) correct—The dressing should be discarded after being wrapped in the non sterile glove.

Which is a priority nursing goal in the plan of care for a client diagnosed with paralysis due to stroke? 1. Maintain adduction of the affected shoulder. 2. Prevent flexion of the affected extremities .3. Observe active range of motion (ROM) daily to all extremities. 4. Maintain external rotation of the affected hip.

(1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder (2) correct—flexor muscles are stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistance from nurse (4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed

The nurse cares for the client in the emergency room. Before administering calcium gluconate 10% 500 mg IV stat, which assessment should the nurse complete FIRST? 1. Stability of the respiratory system. 2. Adequacy of urine output. 3. Patency of the vein. 4. Availability of magnesium sulfate injection.

(1) unnecessary in this situation (2) unnecessary in this situation (3) correct—if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant

The client is placed on cephalexin monohydrate prophylactically after surgery. Which foods should the nurse encourage? Select all that apply. 1. Bran cereals.2. Egg whites.3. Yogurt.4. Fish.5. Acidophilus milk.

(1) unnecessary to encourage (2) unnecessary to encourage (3) correct—this food will help maintain normal intestinal flora, which may be altered by the cephalexin (4) unnecessary to encourage (5) correct—this food will help maintain normal intestinal flora, which may be altered by the cephalexin

The client reports chronic constipation to the nurse. The nurse in the health care clinic should advise the client to take which action? Select all that apply. 1. Reduce intake of highly seasoned foods and fats. 2. Drink 1,000 ml of fluids daily. 3. Increase intake of cereals, fresh fruits, and vegetables. 4. Ask the health care provider to prescribe bisacodyl 5 mg enteric-coated tablets daily. 5. Plan the day to be home around the usual time of defecation. 6. Establish daily exercise pattern.

(1) unnecessary, no effect on constipation (2) normal intake 1,500-2,000 ml, reduced intake causes constipation (3) correct—bulk-forming foods help with constipation (4) passing the buck, laxatives are a last resort (5) correct—establishing a particular time in the home helps establish bowel routine decreasing constipation. (6) correct—Exercise accumulates bowel function decreasing constipation.

The nurse cares for clients in an acute care facility. The nurse identifies which client as a likely candidate for developing acute kidney injury? 1. A young client with recent ileostomy due to ulcerative colitis. 2. A middle-aged client with elevated temperature and chronic pancreatitis. 3. A teenager in hypovolemic shock following a crushing injury to the chest. 4. Child with compound fracture of the right femur and massive laceration of the left arm.

(1) usually ileostomy clients do not experience severe hypovolemia, which would lead to kidney injury problems (2) this type of infection and inflammation does not lead to acute kidney injury (3) correct—common cause of acute kidney injury is kidney ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute kidney injury

The client is diagnosed with metastatic cancer with a poor prognosis. Recently, the client reports increased pain, is less communicative, very irritable, and anorexic. Which nursing goal should be a priority at this time? 1. Encourage client to talk about the possibility of dying. 2. Provide pain assessment and effective pain management. 3. Manage nutrition and hydration. 4. Verify that the health care provider has discussed the prognosis with the family.

(1) will be difficult if client's pain is not adequately controlled (2) correct—comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important but will be difficult if client's pain is not adequately controlled (4) not highest priority

The nurse conducts preoperative teaching with the family of a client scheduled for a total laryngectomy. Which statement, if made by the family, indicates to the nurse a need for further teaching? Select all that apply. 1. "We will need to learn other ways to communicate with each other." 2. "My husband will require a feeding tube for several months." 3. "My father will require a special kind of tube in his neck for his airway." 4. "Dad may develop some difficulty with taste and smell after the surgery." 5. "Dad is looking forward to learning how to laugh using tracheoesophageal puncture." 6. "We will encourage Dad to cough and deep breathe after surgery."

(1) will communicate in writing initially, then by artificial larynx or esophageal speech (2) correct—requires nutritional support for 10 days until wound heals, then gradually resumes oral intake (3) will require laryngectomy tube to prevent scar tissue contracture (4) common with total laryngectomy (5) correct—will not be able to sing, whistle, or laugh using laryngeal communication (6) appropriate action

The nurse plans care for the client hospitalized with bipolar disorder. While the client is in the manic phase, the nursing plan should include which intervention? Select all that apply. 1. Explain procedures in depth. 2. Distract the client with light physical activities 3. Isolate the client until manic phase is resolved 4. Concisely remind the client about the rules. 5. Provide prn medication for all inappropriate behaviors.

(1) will not be effective in changing behaviors, requires an attentive listener (2) correct—client experiences hyperactivity, poor concentration, and distractibility ; redirect into activity that promotes nourishment; are light activity (3) isolation not required, would increase anxiety and hostility (4) correct—clear concise information is appropriate (5) prn medication is a last result and used when physical harm is anticipated.

The client diagnosed with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The nurse notes the client keeps sliding down in bed. The nurse should take which action? 1. Elevate the client's left thigh on two pillows. 2. Elevate the foot of the bed on blocks. 3. Raise the knee gatch on the bed 30°. 4. Instruct the client to remain in the middle of the bed.

(1) will not prevent client from sliding down; may change pull of traction (2) correct—will keep leg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the client from sliding down in bed

The nurse assesses the infant with a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which nursing action is MOST appropriate? 1. Elevate the head of the bed. 2. Suction the infant's mouth and nose. 3. Position the infant on one side. 4. Administer oxygen until breathing is easier.

(1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct—will facilitate drainage of mucus from upper airway and will promote adjustment to breathing through the nose (4) does not relieve the congestion

The nurse cares for a client after a bronchoscopy. The nurse is MOST concerned if which finding was observed? 1. Depressed gag reflex. 2. Sputum streaked with blood. 3. Tachypnea .4. Complaints of a sore throat.

(1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct—client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure

The multipara client comes to the prenatal clinic during her fifth month of pregnancy. The client reports that her breasts are sensitive and sore. Which suggestion by the nurse is best? Select all that apply. 1. "Apply warm compresses to your breasts, and take two aspirin as needed." 2. "Massage your breasts with lotion in a downward motion." 3. Apply cool compresses to the sides of your breasts." 4. "Take an herbal diuretic once a day." 5. Wear a well fitting supportive bra."

(1) would increase circulation and increase discomfort (2) not effective in decreasing discomfort (3) correct—during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue cool packs will decrease the discomfort caused by this change (4) medications are to be avoided during pregnancy (5) correct—appropriate support of the breast will help decrease the feeling of pulling and the discomfort associated with that occurrence.

A client who attends an outpatient clinic is taking chlorpromazine hydrochloride 100 mg tid. The client reports to the nurse that he is sleeping through the day. Which action by the nurse is MOST appropriate? 1. Contact the health care provider to change the dose to 100 mg BID. 2. Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs. 3. Instruct the man to take frequent naps during the day. 4. Encourage the man to be more active during the day.

1) 300-400 mg/day is needed to treat psychosis (2) correct—will reduce daytime sedation (3) won't decrease sedation from medication (4) won't decrease sedation from medication

A client is to receive the afternoon dose of nifedipine. The nurse notes this rhythm on the cardiac monitor. (Bradycardia) Which action is most appropriate for the nurse to take? 1. Withhold the medication. 2. Check the urinary output. 3. Administer the medication. 4. Increase the potassium intake.

1) CORRECT - Nifedipine is a calcium channel blocker used as an antihypertensive. Bradycardia is an adverse effect. Withholding medication and checking with the health care provider is appropriate. 2) Assessment: This is an appropriate nursing action for a client on an antihypertensive that has diuretic effects because of increased blood flow to the kidney but is not a priority in this instance. 3) This is unnecessary. 4) This is an appropriate nursing action for a client on an antihypertensive that has diuretic effects because of increased blood flow to the kidney but is not a priority in this instance

The child admitted with failure to thrive has just had a positive sweat test. The nurse anticipates which changes in the child's plan of care? Select all that apply. 1. Administration of replacement enzymes. 2. Immediate arterial blood gas. 3. A salt-restricted diet. 4. Limited activity with physical therapy. 5. Social service referral. 6. An unrestricted fat diet.

1) CORRECT - sweat test is a positive finding for cystic fibrosis; enzyme replacement therapy is necessary 2) no data in this situation to indicate the child is having pulmonary problems 3) salt is increased in diet 4) physical activity as tolerated increases pulmonary function 5) CORRECT - multi-disciplinary care is required for children with this diagnosis 6) CORRECT - unrestricted fat diet is required due to the malabsorption of fat

The nurse teaches the client being discharged on risperidone. Which client statements indicate the teaching has been successful? Select all that apply. 1. "I may gain weight when taking this medication." 2. "I should avoid extreme temperatures." 3. "I can take over-the-counter sedatives if I have trouble sleeping." 4. "I can drink alcohol as long as I drink in moderation." 5. "I will wear long sleeves when I am out in the sun." 6. "I will change positions slowly."

1) CORRECT — causes weight gain 2) CORRECT — medication impairs body temperature regulation 3) check with health care provider before taking any OTC medication 4) check with health care provider before ingesting alcohol 5) CORRECT — causes photosensitive reactions 6) CORRECT — minimizes orthostatic hypotension

The client admitted with metastatic cancer has received chemotherapy for three months. Lab values include RBC 3.8 million/mm3 (3.8 x 1012/L), WBC 3,000/mm3 (3.0 x 109/L), Hgb 9.3 g/dL (5.8 mmol/L), platelets 50,000/mm3 (50 x 109/L). Which symptoms does the nurse expect the client to exhibit? 1. BP 120/70 mm Hg, pulse 100 bpm, respirations 22 breaths per minute. 2. Ankle edema and ascites. 3. Flushed face and light colored stools .4. Nausea, anorexia, and vomiting.

1) CORRECT — increased pulse and respirations are caused by decreased oxygenation of tissues; normal respiratory rate is 12 to 20 breaths per minute; normal pulse is 60 to 100 beats per minute 2) no information to suggest this is provided in the question 3) will be pale because of anemia 4) not related to information provided in the question

The 9-year-old client has an ostomy. Which statement by the parents indicates the parents are providing quality home care? 1. "We change the bag at least once a week, and we carefully inspect the stoma at that time." 2. "We change the bag every day so we can inspect the stoma and the skin." 3. "We encourage our child to watch TV while we change the ostomy bag." 4. "We only have to change the ostomy bag every 10 days."

1) CORRECT — ostomy bags should be changed at least once a week; good time for stoma to be closely inspected 2) bag should be changed at least once a week or when seal around stoma is loose or leaking 3) does not encourage client participation or foster independence 4) bag should be changed more often

The charge nurse reviews care for the client with internal radiation. The charge nurse intervenes if which actions are noted? Select all that apply. 1. Visitors are limited to 5 hours per day with the client. 2. A male caregiver is assigned to all care. 3. Time in the room is limited for all care providers .4. Lead-lined apron is worn for all care delivery. 5. Verbal exchanges with the client are made from the doorway. 6. Frequent rest periods are incorporated into client's care.

1) CORRECT — this is an incorrect statement; all visitors are restricted with regard to the distance they should be from the client, with most text citing 3 hours per day is recommended 2) CORRECT — this is an incorrect statement; caregivers are not to be assigned all care no matter their gender 3) this is a correct statement; principles for radiation therapy are time, distance, shielding; the nurse should decrease the time spent in close proximity to the client 4) CORRECT — this is an incorrect statement; appropriate shielding (lead apron) is to be used when the nurse has to spend any length of time at a close distance, but not for routine care 5) this is a correct action; the distance decreases close exposure for the care provider 6) this is a correct action; radiation implants can cause fatigue and frequent rest periods are appropriate

A client undergoes admission from the recovery room with an intravenous fluid infusing at 100 mL/hour. There are 900 mL left in the bag. One hour later, the client has received 850 mL. The nurse is most concerned by which assessment finding? 1. A CVP reading of 8 mm Hg and bradycardia. 2. Tachycardia and hypotension. 3. Dyspnea and oliguria. 4. Rales and tachycardia.

1) The CVP reading is normal. Normal CVP ranges are 2-8 mm Hg or 3-11 cm H2O. Bradycardia is not related to a sudden influx of fluid. 2) Tachycardia may be associated with a fluid overload. However, hypotension is not relevant to fluid overload. 3) Dyspnea (shortness of breath) and oliguria (lack of urine output) are not related to a fluid overload. 4) CORRECT - Rales indicate fluid in the lungs and tachycardia indicates cardiovascular fluid overload. These would both be associated with a sudden fluid overload.

The nurse provides care for a client diagnosed with hypovolemia. Which observation does the nurse identify as the desired response to fluid replacement? 1. Urine output 160 mL in 8 hours. 2. Hemoglobin 11 g/dL (110 g/L). 3. Arterial pH 7.34. 4. Central venous pressure (CVP) of 8 mm Hg.

1) Urine output should be at least 30 mL/hr to be considered normal. A urine output of 160 mL in an 8 hour period is equivalent to 20 mL/hr; therefore, this indicates a hypovolemic state. 2) This finding indicates a hypervolemic state. 3) This finding indicates acidosis. 4) CORRECT - The normal range for CVP is 2 to 8 mm Hg (3 to 11 cm of water). A CVP of 8 mm Hg (11 cm of water) indicates a desired response to fluid replacement.

A client has a chest tube inserted for treatment of a hemothorax. Which finding indicates to the nurse that there is a problem with the effective functioning of the chest tube? 1. Fifteen centimeters of water is present in the suction control chamber. 2. Constant bubbling is observed in the water seal chamber. 3. Two centimeters of water is present in the water seal chamber. 4. Clots of blood are observed in the collection chamber.

1) appropriate, regulates the amount of suction delivered to the client (2) correct—would indicate an air leak, would not allow negative pressure to be re-established and would hinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding

The nurse cares for the client following a cardiac catheterization. Two hours after the procedure, the nurse checks the client's insertion site in the antecubital space. The client reports the hand is numb. The nurse takes which action? 1. Changes the position of the client's hand. 2. Checks the client's grip strength in both hands. 3. Notifies the health care provider. 4. Instructs the client to exercise the fingers.

1) assumes that numbness is related to positioning of hand, not circulatory changes 2) part of assessment but doesn't indicate status of circulation 3) CORRECT — absent or weak pulse or numbness could indicate problem with circulation; anticoagulants and vasodilators may be ordered 4) assumes that numbness is related to immobility of fingers, not circulatory changes

The nurse instructs the client being discharged on tranylcypromine sulfate. The nurse determines further teaching is needed if the client makes which statement? 1. "To celebrate, my wife and I are going out for pepperoni pizza and wine tonight." 2. "I plan to use sunblock at the beach this summer." 3. "When I get home, I am going to start a diet so that I can lose some weight." 4. "Now that I feel so much better, I have more energy."

1) correct—Tranylcypromine sulfate is an MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes three to four weeks to work

The nurse performs the physical examination on the newborn. Which nursing assessments should be reported to the health care provider? Select all that apply. 1. Head circumference of 40 cm. 2. Chest circumference of 32 cm. 3. Circumoral cyanosis 4. Heart rate 160. 5. Respirations 80. 6. Edema of the scalp

1) correct—average circumference of the head for a neonate ranges from 32-36 cm; increase in size may indicate hydrocephaly or increased intracranial pressure (2) normal newborn assessment (3) correct—cyanosis of the mucous membranes may be an indication of hypoxia. (4) normal newborn assessment (5) correct—Normal respiratory rates are between 30-60 bpm (6) normal finding due to delivery.

A mother brings her 7-year-old daughter to the outpatient clinic for a routine check-up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that the child has gained 2.5 lb and grown 3 inches in the past year. Which of the following responses by the nurse is BEST? 1. "Your daughter's height and weight are within normal limits." 2. "Your daughter's height is normal, but she needs to gain some weight. "3. "Your daughter's height is normal, but she needs to lose some weight." 4. "Your daughter's weight is normal, but she is shorter than normal."

1) correct—between ages 6-12, children grow about 2 inches (5 cm)/year and gain 4.5-6.5 lb (2-3kg)/year; at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 inches (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits

The client is seen in the clinic reporting back pain. The nurse discusses and demonstrates how to perform activities of daily living to decrease the incidence of back pain. Which action, if performed by the client, indicates to the nurse that further teaching is needed? Select all that apply. 1. The client bends over to put on and tie her tennis shoes. 2. The client stands on her toes to place a box on the top shelf of a closet. 3. The client sits in a recliner with her feet elevated to watch TV. 4. The client stands with her feet close together and shifts her weight between her feet. 5. The client squats to pick up a spoon on the floor. 6. The client places their right leg on top of the left while reading.

1) correct—causes stress on lumbar region of back (2) correct—causes stress on lower spine (3) provides lumbar flexion, decreasing pressure on lower spine (4) correct—should have feet apart for wide base of support (5) Decreases stress on the lower back (6) correct—Turns the lower spine causing stress.

The nurse reviews health care provider's orders. The nurse determines which order warrants further clarification? 1. Administer haloperidol 5 mg. 2. Instruct client to use incentive spirometer q 1 hour while awake. 3. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/hour. 4. CBC with differential and platelets at 0800.

1) correct—has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification

The nurse enters the room of a client and finds that the tracheostomy tube inserted two days ago has been accidentally dislodged. The nurse should take which action? 1. Immediately replace the tracheostomy tube. 2. Suction the client's airway using sterile technique. 3. Provide oxygen at 8 L/minute per mask over the stoma. 4. Check for bilateral breath sounds immediately.

1) correct—implementation; will secure the airway (2) implementation; will not provide for open airway (3) implementation; will not help with open airway (4) assessment; should be done after tracheostomy tube is replaced

A 24-year-old woman at 30 weeks' gestation is seen in the outpatient clinic for a routine visit. The nurse is MOST concerned if the client makes which statement? 1. "During the day I seem to get hot flashes and chills." 2. "I am having some trouble with constipation and hemorrhoids." 3. "At the end of the day I have leg cramps." 4. "When I put my hand on my abdomen, I can feel it tense and relax."

1) correct—should be reported to the health care provider (2) common due to pressure of growing fetus (3) common due to compression of nerves supplying lower extremities or reduced calcium levels; should take oral calcium supplements if ordered; stretch until spasm is relieved (4) Braxton-Hicks contractions common, should rest and change position

The nurse cares for the client after delivery of a 7 lb 10 oz baby boy. The client has decided to bottle-feed her infant. The nurse should encourage the client to take which action? Select all that apply. 1. Use acetaminophen po as directed. 2. Apply cool packs around the outside of each breast. 3. Massage the breasts. 4. Wear a well-supportive bra 24 hours a day. 5. Use the manual breast pump to relieve pressure. 6. Be patient, the milk will resolve in 5-7 days.

1) correct—will decrease discomfort and encourage the client to follow treatment plan. (2) correct—will decrease milk production (3) may be taut due to engorgement; massage would be painful and unnecessary, will encourage milk flow (4) correct—will help minimize discomfort during period of engorgement; will decrease let down effect (5) will scourge and continue milk production. (6) correct—patience is required for the natural process to occur. Engorgement usually resolves on it's own in 5-7 days.

During the nursing history interview, the preschooler's parent reports the child has frequent bouts of gastroenteritis. Which question is most important for the nurse to ask? 1. "Are there other children in the family?" 2. "Does the child attend a day care center?" 3. "Does the child play with neighborhood children?" 4. "Is the child current on the immunizations?"

1) does not pose a problem or solution regarding gastroenteritis 2) CORRECT — environments with increased numbers of children (day care centers) are more likely to promote infections due to close living conditions and increased likelihood of disease transmission 3) possible source of infection but not as likely as a day care center 4) does not pose a problem or solution regarding gastroenteritis

An adult multipara client is seen in the prenatal clinic. The nurse notes the client is in the fifth month of pregnancy and has a weight gain so far of 14 lb (6.36 kg). The history indicates the client was of average height and weight prenatally. The nurse knows which statement is most likely true? 1. The client has gained too much weight, and the diet should be re-evaluated. 2. The client has not gained enough weight, and the diet should be re-evaluated. 3. The weight gain is appropriate, and the present diet should be continued. 4. The weight gain indicates possible difficulties may occur later in the pregnancy.

1) excessive weight gain is >6.6 lb (3 kg)/month 2) inadequate weight gain is <2.2 lb (1 kg)/month 3) CORRECT — weight gain 2-5 lb (0.9-2.27 kg) first trimester, 0.66-1.1 lb (0.3-0.5 kg) weekly in second and third trimester 4) not substantiated by information presented in question

The client is admitted with these symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client receives 80 mg of furosemide. Which nursing observation is most important to report to the next shift? 1. Reports of nausea and vomiting. 2. Urine output of 200 mL in two hours. 3. Quiet and withdrawn behavior after lunch. 4. Blood pressure changes from 160/90 to 150/90.

1) further signs and symptoms of right-sided heart failure; not a priority 2) CORRECT — furosemide is diuretic, which warrants close observation of the client's urine output 3) further signs and symptoms of right-sided heart failure; not a priority 4) may occur as a result of volume loss but is not a priority over evaluation of urine output

The nurse prepares the client for a lumbar puncture. It is important that the nurse makes which statement? Select all that apply. 1. "Don't worry because a general anesthetic will be used." 2. "You can't drink fluids for eight hours before the test .3. "You will remain flat in bed for eight hours after the test." 4. "A compression bandage will be in place for 10 hours after the test." 5. "You may feel discomfort in your leg when the needle is inserted." 6. "You can have analgesics after the procedure if you have a headache."

1) general anesthetic is not used (2) fluids are not restricted before the test (3) correct—to prevent a post-lumbar puncture headache, client should remain flat in bed for eight hours after the test (4) inappropriate for this procedure (5) correct—nerve endings may be touched when performing the procedure. (6) correct—headaches or discomfort may be experienced after the procedure sans pain control can be provided by analgesics.

The client is admitted to the hospital with dry mucous membranes and decreased skin turgor. The client's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the health care provider to order which IV fluids? 1. D5NS. 2. 0.45% NaCl. 3. 0.9% NaCl. 4. Lactated Ringer's.

1) hypertonic solutions contraindicated in dehydration (2) correct—hypotonic solution, shifts fluid into intracellular space to correct dehydration (3) isotonic solution, not best with dehydration (4) isotonic solution used to replace electrolytes

The RN talks to the parents of a 6-month-old. They discuss ways to minimize the adverse effects of a DTaP immunization. Which actions are important for the RN to discuss? Select all that apply. 1. Give the child an alcohol bath for an elevated temperature. 2. Administer acetaminophen for discomfort. 3. Place a cool cloth on the injection site for 15 minutes. 4. Check the child's temperature every four hours for three days. 5. Wrap and comfort the child for signs of irritability. 6. Administer a salicylate medication for a fever.

1) implementation; not recommended for treatment in 6 month old 2) CORRECT — implementation; antipyretics (excluding salicylates) relieve discomfort 3) CORRECT — implementation; cool (not cold) is used to decrease pain; should be used for short temporary intervention 4) assessment; unnecessary unless indicated for another reason 5) CORRECT — decreased moving of the extremity and parental comfort is an appropriate intervention 6) salicylates are not recommended for children.

The nurse stabilizes the client with severe multiple trauma injuries from a motor vehicle accident. Which action does the nurse take next? 1. Limits visiting hours to promote optimal rest. 2. Arranges for clergy to visit with the client and family as requested. 3. Arranges for a psychologist to visit with the family. 4. Arranges for the family to meet with a social worker to discuss financial aid.

1) inappropriate 2) CORRECT — provides the appropriate spiritual support during a crisis 3) inappropriate for the data given in the situation 4) inappropriate for the data given in the situation

The nurse cares for the client twenty-four hours after abdominal surgery. Which action is a PRIORITY for the nurse to prevent complications of flatulence? 1. Encourage the client to drink carbonated beverages daily. 2. Instruct the client to turn from side to side. 3. Encourage the client to do leg exercises in bed. 4. Assist the client to walk in the hall every two hours.

1) increasing carbonated beverages will increase flatus (2) will prevent postoperative complications but not flatulence (3) does not address flatulence (4) correct—will increase peristalsis, decreasing the development of flatus

The clinic nurse receives a call from the parent of a 12-year-old child receiving albuterol. The child is irritable and the parent states, "I can feel my child's heart pounding." Which response by the nurse is most appropriate? 1. Instruct the parent to decrease external stimuli in the child's room. 2. Ask the parent to administer an ordered analgesic. 3. Ask the parent how long the child has been taking the medication. 4. Explain to the parent that this is expected.

1) may help the client cope with current symptoms but is not highest priority 2) nervousness, restlessness, and palpitations are adverse effects of albuterol 3) CORRECT — adverse effects may diminish after child takes the medication a week or longer 4) does not take action to resolve the problem

The nurse cares for the client with a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the client in respiratory distress. Which action does the nurse take first? 1. Notifies the health care provider immediately to remove the tube. 2. Elevates the head of the bed, and administers oxygen. 3. Cuts the balloon ports and removes the tube. 4. Calls a code and begins rescue breathing.

1) need to remove tube immediately to provide for airway 2) does not provide a patent airway 3) CORRECT — scissors always secured at the bedside; remove tube if observing signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon 4) unnecessary to call code until respiratory arrest occurs; establish a patent airway first

The postoperative client returns to the assigned room from the surgical recovery area. The client is sleeping, and the nurse notes the client is disoriented when aroused. Which nursing action is best? 1. Place the call bell within the client's reach. 2. Stay with the client until the client is totally oriented. 3. Restrain all four extremities until the client is oriented. 4. Elevate the side rails until the client is fully awake.

1) not a safety action for a disoriented client 2) unnecessary to stay with the client, especially while client is sleeping 3) restraints are unnecessary at this time 4) CORRECT — side rails should always be elevated for any disoriented client

The mother of a 4-year-old boy comes to the prenatal clinic to confirm her second pregnancy. During the initial visit, it is MOST important for the nurse to take which action? 1. Assess the client's feelings about pregnancy, labor, and delivery. 2. Obtain a history of the client's last labor and delivery. 3. Determine how the client's 4-year-old feels about the pregnancy. 4. Identify the client's general health needs.

1) physical needs take priority (2) physical needs take priority (3) priority is taking care of pregnant client (4) correct—optimal opportunity for preventive health maintenance

The visiting nurse evaluates the progress of the client recently diagnosed with type 1 diabetes. As part of the treatment plan, the client receives intermediate-acting insulin 32 units and short-acting insulin 8 units each morning. Which client actions while preparing the morning insulin injection require an intervention by the nurse? Select all that apply. 1. After drawing up 8 units of short-acting insulin, the client adds intermediate-acting insulin to the syringe for a total of 40 units. 2. The client draws up 32 units of the intermediate-acting insulin first. 3. The client injects air into the intermediate-acting insulin vial then draws up 32 units. 4. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn. 5. After drawing up the intermediate-acting insulin, the client injects air into the short-acting insulin vial. 6. The client cleans the vials with a new alcohol wipe.

1) short-acting insulin always drawn up first; this is a correct action 2) CORRECT — short-acting insulin is clear and drawn up first, only 8 units are ordered; intermediate-acting insulin is cloudy 3) CORRECT — after injecting air the client should withdraw the syringe to inject air into the other vial before withdrawing any insulin 4) allows you to withdraw medication later 5) CORRECT — air is injected before withdrawing the other insulin. 6) this is a correct action

The nurse cares for the client after a radical mastectomy of the right breast. Upon return to the unit, which position is most appropriate for the nurse to assist the client into? 1. Position the client on the left side with the right arm protected in a sling. 2. Position the client on the right side with the right arm elevated. 3. Position the client in semi-Fowler's position with the right arm elevated. 4. Position the client in the prone position with the right arm elevated.

1) sling is not necessary, arm needs to be elevated 2) right arm cannot be elevated from this position 3) CORRECT — this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema 4) prone position is not appropriate

The nurse cares for the client diagnosed with dementia in a long-term care facility. Which action by the nurse is best? 1. Encourage the client to verbalize feelings about being placed in a nursing home. 2. Ask the client what favorite pastimes and what types of activities the client used to participate in. 3. Orient the client to the present time and assist the client to be alert and oriented when the family comes to visit. 4. Direct conversation toward assisting the client to reminisce and talk about important past events in life.

1) the client may not remember own identity or location 2) not as important as encouraging reminiscences 3) even with orientation, the client soon forgets 4) CORRECT — geriatric client should be encouraged to talk about past life and important things in the past because the client has recent memory loss

The emergency department nurse cares for the client demonstrating these symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend tells the nurse that the client used hallucinogenic drugs. Which action does the nurse take? 1. Places the client in full restraints. 2. Decreases environmental stimulation. 3. Calls the security guards. 4. Administers a PRN dose of chlorpromazine.

1) unnecessary at this time 2) CORRECT — symptoms will subside with time and decreased stimulation 3) unnecessary at this time 4) inappropriate

The nurse cares for a client diagnosed with pneumonia. Which observation indicates a therapeutic response to the treatment? 1. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough. 2. Cough, productive of thick, green sputum, client reports feeling tired. 3. Respirations at 20 with moderate amount of thin, white sputum, denies dyspnea. 4. White cell count of 10,000 mm3, urine output at 40 ml/hour, decreasing amount of sputum.

1) validates the continued presence of the infection (2) validates the continued presence of the infection (3) correct—sputum characteristics indicate a decrease in the pneumonia; is supported by respiratory status (4) does not substantiate the status of the infection

The nurse has just returned to the desk and has four phone messages to return. Which message should the nurse return FIRST? 1. A man with swelling of his left wrist following a fall from a ladder two hours ago. 2. A woman who had a cholecystectomy one week ago and now reports of redness and tenderness at the incision site. 3. A mother of a child reports that her son's lips are swollen following a fire ant bite. 4. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101°F (38.4°C).

1) wrist needs to be x-rayed, not a priority (2) indicates infection, treated with antibiotic (3) correct—potential anaphylactic reaction, administer epinephrine, corticosteroids; treat for shock (4) indicates infection, treat with antibiotic

The nurse cares for clients on the surgical floor and has just received report from the previous shift. In which order should the nurse assess the clients?

1. 62 year old male who had an abdominal perineal resection 3 days ago and reporting chills 1) See first; Unstable, unexpected, real problem peritonitis, should be assessed for further symptoms of infection 2. 59 year old with a collapsed lung; no drainage noted from chest tube placed 8 hours ago (2) See second, Unstable, expected, respiratory, resolution (chest tube placed) 3. 35 year old admitted with gun shot wound three hours ago; 1/5 cm dark drainage on dressing (3) See third; Unstable, expected, circulation, potential 4. 43 year old 2-day old mastectomy; 23 ml of serangous fluid in jp drain (4) See last; Unstable, expected, potential

The nurse admits the client from the postoperative recovery area after abdominal exploratory surgery. In which order should the nurse perform the actions?

1. Assess the respiratory rate (1) This is the first action. respiratory assessment is highest priority. 2. Assess the pulse (2) 2nd action to perform. assessment of cardiac status is second priority. 3. Check the dressing for evidence of bleeding (3) assessment; dressing should be checked on admission to the room and frequently for the next several hours 4. Position the client on left side (4) 4th action; implementation but priority assessments should be completed first 5. Check the chart for surgical notes (5) 5th action; knowing what occurred in surgery is an action but assessment and position the client will take priority. 6. Monitor the incision site for purulent drainage (6) 6th action; baseline assessment would be required but much to soon for infection assessment

The client develops severe, crushing chest pain radiating to the left shoulder and arm. Which medication does the nurse administer? 1. Diazepam PO.2. Fentanyl IM.3. Morphine sulfate IV.4. Clopidogrel PO.

Think MONA 1) not an appropriate medication in this situation; antianxiety medication 2) fentanyl decreases pain but does not vasodilate to relieve cardiac workload 3) CORRECT — morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload 4) platelet aggregation inhibitor; initial therapy is aspirin