Quiz 1-Synthesis

After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply 1. I will avoid eating meat for 1-3 days before getting a stool sample 2. I need to eat foods low in fiber a few days before collecting the sample 3. Ill take the sample from different areas of the stool that I have passed. 4. I need to send the stool sample to the lab in a covered container right away 5. I can continue to take all of my regular medications at home

1, 3

While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out but theyre still there" After assessing the neonate's mouth, the nurse explains that these spots are which of the following? 1. Koplik's spots 2. Epstein's pearls 3. Precocious teeth 4. Thrush curds

2

The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms? 1. Sore throat and muscle aches. 2. Nausea and flushing of the face and neck 3. Fever and muscle soreness 4. Bradycardia and vertigo

2. The client who drinks alcohol while taking disulfiram experiences sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations, dyspnea, tremor and weakness.

An elderly client is being admitted to same day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that 1. The rings will be taped before the surgery 2. The rings will be placed in an envelope, the client will the envelope and the envelope will be placed in a safe. 3. The rings will be locked in the narcotics box 4. The nursing supervisor will hold onto the rings during the surgery.

2. Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables

The nurse should assess the client with severe acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3

A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following? 1. Varicocele 2. Frequent use of saunas 3. Endocrine imbalances 4. Decreased body temperature

4

Which of the following statements made by a pregnant woman in the first trimester are consistent with this stage of pregnancy? Select all that apply 1. My husband told his friends we will have to give up the Mustang for a minivan. 2. Oh my, how did this happen? I don't need this now. 3. I cant wait to see my baby. Do you think it will have my blond hair and blue eyes? 4. I used a Disney theme for decorating the room 5. I wonder how it will feel to buy maternity clothes and be fat. 6. We went to a mall yesterday to buy a crib and dressing table.

1, 2, 5 The first trimester is when the couple works through the psychological task of accepting the pregnancy. These statements describe the client and her partner coping with the pregnancy, how it feels and how it will impact their lives. the feelings include pleasure, excitement and ambivalence. Wondering what the baby will look like and planning for the baby's room occur later in the pregnancy.

Which of the following responses is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away? 1. When you interrupt others, they leave the area 2. You are being rude and uncaring 3. You should remember to use your manners 4. You know better than to interrupt someone

1. Saying this is most helpful because it serves to increase the client's awareness of others' perceptions of the behavior by giving specific feedback abut the behavior. The other statements are punitive and authoritative, possibly threatening to the client, and likely to increase defensiveness, decrease self-worth, and increase feelings of guilt.

When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier: 1. Provides an outlet for emotional tension 2. Indicates readiness to take solid foods 3. Indicates intestinal motility 3. is an attempt to get attention from the parents

1. Sucking provides the infant with a sense of security and comfort. It is also an outlet for releasing tension. the infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant's appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention

A client asks the nurse how long it will be necessary to take the medicine for hypothyroidism. The nurse's response is based on the knowledge that: 1. Lifelong daily medicine is necessary 2. The medication is expensive and the dose can be reduced in a few months 3. The medication can be gradually withdrawn in 1-2 years. 4. The medication can be discontinued after the client's TSH level is normal

1. Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the TSH level is normal; the dose will be maintained at the level that normalizes the TSH concentration.

A client is trying to lose weight at a moderate pace. If the client eliminates 1000 cal/day from his normal intake, how many pounds would the client lose in 1 week?

2 lb

The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below (palpating the head which is nearest the cervix and is the presenting part). Which of the following maneuvers is the nurse performing? 1. First maneuver 2. 2nd 3. 3rd 4. 4th

3

A client with angina shows the nurse the nitroglycerin that the client carries in a plastic bag in the pocket. The nurse instructs the client that the nitroglycerin should be kept in: 1. The refrigerator 2. A cool, moist place 3. A dark container to shield from light 4. A plastic pill container where it is readily available

3. Nitroglycerin in all dosage forms should be shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy and it should not be removed or placed in another container.

When teaching a client with bipolar disorder who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse should instruct the client to report: 1. Increased urination 2. Slowed thinking 3. Sedation 4. Weight loss

3. Valproic acid causes sedation as well as nausea, vomiting and indigestion. Sedation is important because the client needs to be cautioned about driving or operating machinery that could be dangerous while feeling sedated from the medication. Depakene does not cause increased urination, slowed thinking, or weight loss. However some clients may experience weight gain.

A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their VS assessed and a fourth client is on her way to the unit from the ED. In which order of priority should the nurse manage these clients? 1. the client with clear vesicles and brown vaginal discharge at 16 weeks 2. The client with RLQ pain at 10 weeks 3. The client who is at term and has had no fetal movement for 2 days 4. The client from the ED at term and screaming loudly because of labor contractions

4 2 1 3

The nurse holds the gauze pledget against an IM injection site while removing the needle from the muscle. This technique helps to 1. Seal off the track left by the needle in the tissue 2. Speed the spread of the medication in the tissue 3. Avoid the discomfort of the needle pulling on the skin 4. Prevent organisms from entering the body through the skin puncture

3. Holding the gauze pledget against an IM injection site while removing the needle from the muscle avoids the discomfort of the needle pulling on the skin.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. WHich of the following interventions should be included in the plan of care before hydrotherapy treatment is initiated? 1. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting 2. Increase the IV flow rate to offset fluids lost through the therapy 3. Apply a topical antibiotic cream to burns to prevent infection 4. Administer pain medication 30 minutes before therapy to help manage pain

4

A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for contraception. The nurse should instruct the client to increase her intake of which of the following? 1. Folic acid 2. Vitamin C 3. Magnesium 4. Calcium

4. The nurse should instruct the client to increase her intake of calcium because there is a slight increase in the risk of osteoporosis with this medication. Weight-bearing exercises are also advised. The drug may also impair glucose tolerance in women who are at risk for diabetes.

A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following should the nurse instruct the client to do? 1. Take the med immediately 2. Restart the med in the morning 3. Use another form of contraception for 2 weeks 4. Take 2 pills tonight before bedtime

1

After testing a primigravid client at 10 weeks gestation about the recommendations for exercise during pregnancy, which of the following client statement indicates successful teaching? 1. While pregnant, I should avoid contact sports 2. Even though im pregnant, i can learn to ski next month 3. WHile we are on vacation next month, I can continue to scuba dive. 4. Sitting in a hot tub after exercise will help me to relax

1

During the process of restraining a client, a staff member is injured. The nurse manager would conclude that a peer support program has been helpful for the injured staff member if which of the following outcomes had been achieved? Select all that apply 1. The injured staff member has debriefed with the other staff involved in the restraint 2. Legal action has been taken against the client 3. The injured staff member had the opportunity to express his or her feelings with a support group. 4. The injured staff member has decided whether or not to talk to the assaultive client. 5. A plan has been arranged to facilitate the return of the injured staff member to work.

1, 3, 4, 5

A client with major depression states, "Life isn't worth living anymore. Nothing matters." Which of the following responses by the nurse is best? 1. Are you thinking about killing yourself? 2. Things will get better, you know. 3. Why do you think that way? 4. You shouldn't feel that way.

1. When the client verbalizes that life isn't worth living anymore, the nurse needs to ask the client directly about suicide. Asking directly does not provoke suicide but conveys concern, understanding, and the worth of the client. Commonly the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan responsible care by identifying a client at risk.

A client takes hydrochlorthiazide (HCTZ) for treatment of hypertension. The nurse should instruct the client to report which of the following? Select all that apply. 1. Muscle twitching 2. Abdominal cramping 3.Diarrhea 4. Confusion 5. Lethargy 6. Muscle weakness

2, 5, 6 HCTZ is a thiazide diuretic used in the management of mild to moderate HTN and in the treatment of edema associated with heart failure, renal dysfunction, cirrhosis, corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule of the kidneys. It promotes the excretion of chloride, potassium, magnesium and bicarbonate. Side effects include drowsiness, lethargy, and muscle weakness but not muscle twitching, Although there may be abdominal cramping, there is no diarrhea. The client does not become confused as a result of taking this drug.

Which finding requires immediate intervention when planning care for an adolescent with CF? 1. Delayed puberty 2. Chest pain with dyspenea 3. Poor weight gain 4. Large foul-smelling bulky stools

2. Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed but respiratory complications are the greatest concern.

The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate? 1. Cat 2. Fish 3. Gerbil 4. Canary

2. Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold

When a client wants to read the chart, the nurse should 1. Call the health care provider to obtain permiossion 2. Give the client the chart and answer the client's questions 3. Tell the client to read the chart when the doctor makes rounds 4. Answer any questions the client has without giving the client the chart

2. The client should be allowed to see the chart. As a client advocate, the nurse should answer questions for the client. The nurse helps the client become a primary partner in the health team. The Bill of Rights for patients has existed since the 1960s and every client should be aware of this document. The doctor should not need to give permission for the client to see the chart. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing the chart.

A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best? 1. Would you like me to help you tell them? 2. The information you confide in me is confidential. 3. I must share this information with your family. 4. I mist share this information with your employer.

2. The nurse is responsible for maintaining confidentiality of this disclosure by the client

A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. WHich of the following instructions should the nurse give the client in response to this information? 1. Anticipate lesions within 25-30 days 2. COntinue sexual activity unless lesions are present 3. Report any difficulty urinating 4. Drink extra fluids to prevent lesions from forming

3

The nurse is beginning the shift and is planning care for 6 clients on the postpartum unit. Three of the clients are listed as stable. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first? 1. The three clients reported to be stable 2. The mother with a 4 hour old infant with initial blood glucose of 33 mg/dL and now at 45 mg/dL breast-feeding her infant 3. A mother who had a spontaneous vaginal delivery and received methlergonovine maleate (Methergine) 1 hour ago for increased bleeding. 4. A mother with a 3 day old infant who had a bilirubin level of 13 mg/dL 30 minutes ago and is now in a biliblanket at the mothers bedside

3

The nurse is developing a community health education program about STDs. WHich information about women who acquire gonorrhea should be included? 1. Women are more reluctant than men to seek medical treatment. 2. Gonorrhea is not easily transmitted to women who are menopausal 3. Women with gonorrhea are usually asymptomatic 4. Gonorrhea is usually a mild disease for women

3

When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches? 1. Questioning the client about how much alcohol the client consumes each day 2. Confronting the client about being intoxicated 2 days ago 3. Pointing out how alcohol has gotten the client into trouble 4. Listening to what the client states and then asking the client about plans for staying sober

3

Which of the following findings should the nurse note in the client who is in the compensatory stage of shock? 1. Decreased urinary output 2. Significant hypotension 3. Tachycardia 4. Mental confusion

3

A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which of the following? 1. Hallucination 2. Illusion 3. Delusion 4. Paranoia

3. A client with severe depression may experience symptoms of psychosis such as hallucinations and delusions that are typically mood congruent. The statement is a mood congruent somatic delusion. A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.

During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients take an active role in their health care? 1. Ask clients to complete a questionnaire 2. provide clients with written instructions 3. Ask clients for their views of their health and health care. 4. Ask clients if they have any questions about their health.

3. One of the best strategies to help clients feel in control is to ask them their view of situations and to respond to what they say. This technique acknowledges that clients' opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation but alone it does not acknowledge their views.

A client whose condition remains stable after a MI gradually increases activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client? 1. Edema 2. Cyanosis 3. Dyspnea 4. Weight loss

3. Physical activity is gradually increased after a MI while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat or fatigue. When any of these symptoms appear, the client should reduce activity and progress more slowly.

Under which circumstance may a nurse communicate medical information without the clients consent? 1. When certifying the clients absence from work 2. When requested by the client's family 3. When treating the client with a STD 4. When prescribed by another physician

3. Sexually transmitted disease are communicable disease that must be reported. The nurse is responsible for reporting these disease to the appropriate public health agency and to otherwise maintain the client's confidentiality. The client's family cannot request release of medical information without the client's consent. A physician's prescription is not a substitute for a client's consent to release medical information in the absence of a communicable disease.

Assessment of a client taking lithium reveals dry mouth, nausea, thirst and mild hand tremor. Based on analysis of these findings, which of the following should the nurse do next? 1. Withhold the lithium and obtain a lithium level to determine therapeutic effectiveness 2. Continue the lithium and immediately notify the physician about the assessment findings. 3. Continue the lithium and reassure the client that these temporary side effects will subside. 4. Withhold the lithium and monitor the client for signs and symptoms of increasing toxicity.

3. The client is exhibiting temporary side effects associated with lithium therapy.

A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL and blood pressure is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the physician and the family to next: 1. Discontinue all measures 2. Notify the hospital attorney 3. Attempt to stabilize the client through the use of fluid replacement 4. Give enough blood to keep the client from dying

3. The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respect the client's religious beliefs and wishes, even if they are not those of the health care team. Discontinuing all measures is not an option. The health care team should continue to provide the best care possible and does not need to notify the attorney.

A client has been taking imipramine (Tofranil) for depression for 2 days. His sister asks the nurse, "Why is he still so depressed?" Which of the following responses is the most appropriate? 1. Your brother is experiencing a very serious depression 2. Ill be sure to convey your concern to his physician. 3. It take 2-4 weeks for the drug to reach its full effect 4. Perhaps we need to change his medication

3. The nurse needs to inform the sister that it takes 2 to 4 weeks before a full clinical effect occurs with the drug. The nurse should let her know that her brother will gradually get better and symptoms of depression of depression will improve.

A client with a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if the client uses which of the following crutch-walking gaits? 1. Two-point gait 2. Four-point gait 3. Three point gait 4. Swing to gait

3. The three-point gait, in which the client advances the crutches and the affected leg at the same time while weight is supported on the unaffected extremity, is the appropriate gait of choice. This allows for non-weight bearing on the affected extremity. The two-point, four-point, and swing-to gaits require some weight bearing on both legs, which is contraindicated for this client.

A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care? 1. When I injure my toe, I will plan to put iodine on it 2. I should inspect my feet at least once a week 3. It is okay to go barefoot in the house 4. It is important to dry my feet carefully after my bath

4

The nurse should advise which of the following clients who is taking lithium to consult with the physician regarding a potential adjustment in lithium dosage? 1. A client who continues work as a computer programmer 2. A client who attends college classes 3. A client who can now care for her children 4. A client who is beginning training for a tennis team

4. A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs and when a new diet begins.

A 68 year old client's daughter is asking about the follow-up evaluation for her father after pneumonectomy for primary lung cancer. The nurse's best response is which of the following: 1. The usual follow-up is chest x-ray and liver function tests every 3 months. 2. The follow-up for your father will be a chest x-ray and a computed tomography scan of the abdomen every year. 3. No follow-up is needed at this time. 4. The follow-up for your father will be a chest x-ray every 6 months

4. Follow-up generally involves semiannual chest radiographs. Recurrence usually occurs locally in the lungs and may be identified on chest radiographs. Follow-up after cancer treatment is an important component of the treatment plan. Serum markers (liver function tests) have not been shown to detect recurrence of lung cancer. There are no data to support the need for an abdominal computed tomography scan.

At what time should the blood be drawn in relation to the administration of the IV dose of gentamicin sulfate? 1. 2 hours before the administration of the next IV dose 2. 3 hours before the administration of the next IV dose 3. 4 hours before the administration of the next IV dose 4. Just before the administration of the next IV dose

4. To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next IV dose of gentamicin sulfate

The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says: 1. If I think I have a bladder infection, I need to see my obstetrician. 2. If I have contractions, I should contact my HCP 3. Drinking water may help prevent early labor for me 4. If I travel on long trips, I need to get out of the care every 4 hours

4. Traveling is usually discouraged if preterm labor has been a problem, as it restricts normal movement. A client should be able to walk around frequently to prevent blood clots and to empty her bladder at least every 1-2 hours. Bladder infections often stimulate preterm labor and preventing them is of great importance to this client. COntractions that recur indicate the return of preterm labor, and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor and encouraging the client to drink adequate amounts of water helps to prevent this problem

A client who is on NPO status is constantly asking for a drink of water. Which of the following is the most appropriate nursing intervention? 1. Reexplain why it is not possible to have a drink of water 2. Offer ice chips every hour to decrease thirst 3. Offer the client frequent oral hygiene care 4. Divert the client's attention by turning on the tv

3

A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. The fluctuation means that: 1. There is an obstruction in the chest tube 2. The client is developing subcutaneous emphysema 3. The chest tube system is functioning properly 4. There is a leak in the chest tube system

3

A mother tells the nurse that her 10 year old daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation typically occurs within which of the following time frames? 1. 6 months 2. 12 months 3. 30 months 4. 36 months

3

A multigravid client is scheduled for a percutaneous umbilical blood sampling procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following? 1. Twin pregnancies 2. Fetal lung maturation 3. Rh disease 4. Alpha fetoprotein level

3

A 16 year old client is in the emergency room for treatment of minor injuries from a car accident. A crisis nurse is with the client because the client became hysterical and was saying, "It's my fault. My mom is going to kill me. I dont even have a way home." Which of the following should be the nurse's initial intervention? 1. Hold her hands and say, "Slow down and take a deep breath" 2. Say, "Calm down. The police can take you home" 3. Put a hand on her shoulder and say, "It wasnt your fault" 4. Say, "Your mother is not going to kill you. Stop worrying"

1

A HCP has been exposed to Hep B through a needlestick. WHich of the following drugs should the nurse anticipate administering as postexposure prophylaxis? 1. Hep B immune globulin 2. Interferon 3. Hep B surface antigen 4. Amphotericin B

1

The client with a NG tube has abdominal distention. Which of the following measures should the nurse do first? 1. Call the physician 2. Irrigate the NG tube 3. Check the function of the suction equipment 4. Reposition the NG tube

3

The nurse is assessing a client who has had a MI. The nurse notes the cardiac rhythm is shown below. The nurse notes that this rhythm is

4

A client is prescribed atropine 0.4 mg IM. The atropine vial is labeled 0.5 mg/mL. How many milliliters should the nurse plan to administer? ________________________ mL

0.8 mL

A client is scheduled to have surgery to relieve an intestinal obstruction. The nurse receives the following prescriptions for the client. Which of the following prescriptions should the nurse question before performing? 1. Tap water enemas until clear 2. Out of bed as tolerated 3. Neomycin sulfate 1 g PO every 4 hours 4. Betadine scrub to abdomen

1

The nurse recognizes that a client with pain disorder is improving when the client says which of the following? 1. I need to have a good cry about all the pain Ive been in and then not dwell on it 2. I need to find another condition who can accurately diagnose my condition. 3. The pain medicine that you gave me helps me to relax 4, Im angry with all of the doctors Ive seen who don't know what theyre doing

1

The nurse walks into the room of a client who has a DNR prescription and finds the client without a pulse, respirations or BP. The nurse should first? 1. Stay in the room and call the nursing team for assistance 2. Push the emergency alarm to call a code 3. Page the client's physician 4. Pull the curtain and leave the room

1

The nurse hears a pregnant client yell, "Oh my! The baby's coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse see that the neonate's head is delivering. Which of the following should the nurse do first? 1. Suction the mouth with two fingertips 2. Check for presence of a cord around the neck 3. Tell the client to bear down with force 4. Advise the mother that help is on the way

2

A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume? 1. A weight reduction of 10% will occur 2. Pain will be controlled effectively 3. ABG values will be WNL 4. Serum osmolality will be WNL

4

Which of the following statements indicates that the client with a peptic ulcer understands the dietary modification to follow at home? 1. I should eat a bland, soft diet 2, It is important to eat six small meals a day 3. I should drink several glasses of milk a day 4, I should avoid alcohol and caffeine

4

The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish speaking only client with an infant who is in the special care nursery (SCN) for fetal distress. The nurse should place the new client in a room with which of the following clients? 1. A G4 P4 who is 2 days postpartum with infant, Spanish speaking only 2. A G1 P1 who is 1 day postpartum with an infant in the SCN 3. A G6 P6 who delivered 4 hours ago by c/s for fetal distress, infant at bedside 4. A G1 P1 who is a non-English speaking client with infant in SCN for fetal distress

1

A loading doses of digoxin is given to a client newly diagnosed with atrial fibrillation. the nurse instructs the client about the medication and the importance of monitoring his heart rate. An expected outcome of this instruction is: 1. A return demonstration of palpating the radial pulse 2. A return demonstration of how to take the medication 3. Verbalization of why the client has atrial fibrillation 4. Verbalization of the need for the medication

1

A multigravid client at 34 weeks gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of PPROM and preterm labor. The client's contractions are 20 minutes apart, lasting 20-30 seconds. Her cervix is dilated 2 cm. The nurse reviews the physician prescriptions. WHich of the following should the nurse initiate first? 1. Initiate fetal and contraction monitoring 2. Start IV infusion of D5LR 3. Obtain urine specimen 4. Administer betamethasone

1

Which of the following is a priority goal after surgical repair of a cleft lip? 1. Managing pain 2. Preventing infection 3. Increasing mobility 4. Developing parenting skills

2

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistuala (TEF) for which of the following? Select all that apply 1. Copious frothy mucus 2. Episodes of cyanosis 3. Several loose stools 4. Initial weight loss 5. Poor gag reflex

1, 2

A client scheduled for hip replacement surgery wish to receive his own blood for the upcoming surgery. The nurse should 1. Document the clients request on the chart 2. Notify the hematology laboratory 3. Notify the surgeons office 4. Call the blood bank

3

When performing an otoscoic examination of the tympanic membrane of a 2 year old child, the nurse should pull the pinna in which of the following directions? 1. Down and back 2. Down and slightly forward 3. Up and back 4. Up and forward

1

When performing chest percussions on a child, which of the following techniques should the nurse use? 1. Firmly but gently striking the chest wall to make a popping sound 2. Gently striking the chest wall to make a slapping sound 3. Percussing over an area from the umbilicus to the clavicle 4. Placing a blanket between the nurses hand and the childs chest

1

Which of the following factors is most important for healing an infected decubitus ulcer? 1. Adequate circulatory status 2. Scheduled periods of rest 3. Balanced nutritional diet 4. Fluid intake of 1500 mL/day

1

Which of the following is an appropriate outcome for a client with rheumatoid arthritis? 1. The client will manage joint pain and fatigue to perform activities of daily living 2. The client will maintain full range of motion in joints 3. The client will prevent the development of further pain and joint deformity 4. The client will take anti-inflammatory medications as indicated by the presence of disease symptoms

1

The nurse is caring for a toddler in contact isolation for RSV. In what order should the nurse remove PPE> 1. Gloves 2. Goggles 3. Gown 4. Mask

1 3 2 4

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. WHich of the following is the correct care of the specimen? 1. Promptly send the specimen to the laboratory 2. Send the specimen with the next pickup 3. Send the specimen the next time a nursing assistant is available 4. Store the specimen in the refrigerator until it can be sent to the laboratory

1

The physician has prescribed a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical-surgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. WHat is the nurse's most appropriate response? 1. Send the client to the oncology floor for administration of the medication 2. Ask a nurse from the oncology floor to come to the client and administer the medication 3. Ask another nurse to help mix the chemotherapy agent 4. Ask the pharmacy to mix the chemotherapy agent and administer it

1

The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she's getting her memory back!" WHich of the following responses by the nurse is most appropriate? 1. She still has long-term memory, but her short-term memory will not return. 2. Im so happy to hear that. Maybe she is getting better. 3. Dont get your hopes up. This is only a temporary improvement. 4. Im glad she can sing even if she cant talk to you.

1

A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg BID and lamotrigine (Lamictal) 25 mg BID, Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply. 1. Rash 2. Nausea 3. Sedation 4. Hyperthermia 5. Muscle rigidity

1, 4, 5. Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. COmmon adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting and ataxia. The development of a rash needs to be reported and evaluated by the physician because it could indicate the start of Stevens-JOhnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a 1. Micron mesh filter 2. Non filtered blood administration set 3. Special leukocyte-poor filter 4. Microdrip administration set

1. All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte-poor filters and this is recommended to decrease reaction in clients, such as hemophiliacs, who require frequent transfusions. Blood is too concentrated to administer through a microdrip set.

An infant is born with facial abnormalities, growth retardation, mental retardation and vision abnormalities. These abnormalities are likely caused by maternal: 1. Alcohol consumption 2. Vitamin B6 deficiency 3. Vitamin A deficiency 4. Folic acid deficiency

1. These effects and others when seen after birth are known as a cluster of symptoms called fetal alcohol syndrome. Vitamin B6 and vitamin A deficiency can affect growth and development but not with these specific side effects. Folic acid deficiency contributes to neural tube defects.

A 7 year old child is admitted to the hospital with the diagnosis of acute rheumatic fever. Which of the following laboratory blood findings confirms that the child has had a streptococcal infection? 1. High leukocyte count 2. Low hemoglobin count 3. Elevated antibody concentration 4. Low erhythrocyte sedimentation rate

3

A client has been prescribed hydrochlorothiazide (HCTZ) to treat heart failure. For which of the following symptoms should the nurse monitor the client? 1. Urinary retention 2. Muscle weakness 3. COnfusion 4. Diaphoresis

2

A client in cardiac rehabilation would like to eat the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity? 1 Protein 2. Carbohydrate 3. Fat 4. Water

2

A client is receiving digoxin and the pulse range is normally 70-76 bpm. After assessing the apical range for 1 minute and finding it to be 60 bpm, the nurse should first: 1. Notify the physician 2. Withhold the digoxin 3. Administer the digoxin 4. Notify the charge nurse

2

A client with delirium becomes very anxious and says, "I cant stop what is happening to me. Make it stop please!" Which of the following responses is the nurse's most appropriate response? 1. Ill get you some medicine to help you relax. The more you worry, the worse it will get. 2. As soon as we know what's causing this, we can try to stop it. Ill get you some medicine to help you relax 3. I wish i could do something to make it stop, but unfortunately i cant. 4. Ill sit with you until you calm down a little

2

A female client is admitted with fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The nurse should conduct a focused assessment for further signs of: 1. Cushings disease 2. Hypothyroidism 3. Hyperthyroidism 4. A pituitary tumor

2

The nurse assesses a client with diverticulitis. The nurse should report which of the following to the HCP? 1. Hyperactive bowel sounds 2. Rigid abdominal wall 3. Explosive diarrhea 4. Excessive flatulence

2

The nurse is preparing a discharge plan for a 16 year old client who has fractured the femur and ulna. The client asks the nurse how quickly the fractures will heal. Which of the following responses is most appropriate for the nurse to make? 1. The healing of your leg will be delayed because you have had skeletal traction. 2. It will take your arm about 12 weeks to heal but it will take your leg about 24 weeks 3. Because you are young and healthy, your bones should heal in less than 12 weeks 4. You will require long-term rehabilitation and should expect it to take at least 8 months for your bones to heal.

2

When teaching UAP about the importance of handwashing in preventing disease, the nurse should instruct the UAP that 1. It is not necessary to wash your hands as long as you use gloves 2. Hand washing is the best method for preventing cross-contamination 3. Waterless commercial products are not effective for killing organisms 4. The hands do not serve as a source of infection

2

Which of the following is an adverse effect of vancomycin and needs to be reported promptly? 1. Vertigo 2. Tinnitus 3. Muscle stiffness 4. Ataxia

2

The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply. 1. Ask the client to rub lotion over the hands every day after bathing. 2. Encourage physical activity, such as ambulation. 3. Provide frequent contacts for communication and socialization. 4. Provide family education. 5. Encourage involvement of family and friends

2, 3, 4, 5 Socialization and communication, in addition to increased activity, are all means to aid in prevention of self-injury. Education of family members may foster development of strategies to prevent self-injury; hence mitten restraints could be avoided. Applying lotion after bathing may not be appropriate when the skin is broken and not intact.

A 4 year old is brought to the emergency room with sudden onset of a temperature of 103 F, sore throat, and refusal to drink, The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next? 1. Give 600 mg of Tylenol rectally as prescribed 2. Inspect the child's throat for redness and swelling 3. Have an appropriate-sized tracheostomy tube readily available 4. Obtain a specimen for a throat culture

3. The child is exhibiting signs and symptoms of possible epiglottiditis. As a result, the child is at high risk for laryngospasm and airway occlusion. Therefore, the nurse should have a trach tube and setup readily available should the child experience an airway occlusion. Although acetaminophen is an antipyretic, the dosage of 600 mg rectally is too high. A typical 4 year old weighs about 40 pounds. The recommended dose is 125 mg. When any type of respiratory illness and especially epiglottiditis, is suspected, putting any object, including a tongue depressor for inspection or a cotton-tipped applicator to obtain a throat culture, in the back of the mouth or throat or having the child open the mouth is inappropriate because doing so may predispose the child to laryngospasm or occlusion of the airway by a swollen epiglottis

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. Which of the following is the nurse's best response? 1. What has your neighbor doing that bothers you? 2. How long have you been hearing these terrible voices? 3. We wont let your neighbor visit so youll be safe 4. What exactly are these terrible voices saying to you?

4

A client has the leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment? 1. Inability to move toes 2. Cyanosis of toes 3. Sensation of cast tightness 4. Tingling of toes

4

A 22 year old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate poisoning. Which of the following is appropriate for obtaining permission to place a catheter for ICP monitoring? 1. The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married. 2. The physician will get a consultation from another physician and proceed with placement of the ICP catheter until the family arrives to sign the consent. 3. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. 3. The physician will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without a consent.

4. In a life threatening emergency where time is of the essence in saving life or limb, consent is not required.

NSAIDs are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to: 1. take NSAIDs at least 3 times per day 2. Exercise the joints at least 1 hour after taking the medication 3. Take antacids 1 hour after taking NSAIDs 4. Take NSAIDs with food

4. NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs.

The nurse is teaching a client about using topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching? 1. I will avoid being out in the sun for long periods 2. I should stop applying it once the infected area heals. 3. Ill call the physician if the condition worsens 4. I should apply it to large open areas

4. The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas because toxicity and systemic absorption are possible.

The nurse is conducting a counseling session with a client experiencing PTSD using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will: 1. Save travel time from the house to the health care facility 2. Avoid reliving a traumatic event that might be precipitated by visiting a health care facility 3. Experience a shorter recovery time than being treated on-site 4. Receive health care for this mental health problem 5. Obtain group support from others with a similar health problem

1, 2, 4

The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that: 1. A disease carrier also has the disease. 2. Two parents who are carriers may produce a child who has the disease 3. A disease carrier and an affected person will never have children with the disease 4. A disease carrier and an affected person will have a child with the disease

2. Cystic fibrosis is the most common inherited disease in children. It is inherited as an autosomal recessive trait, meaning that the child inherits the defective gene from both parents. The chances are one in four for each of the couples pregnancies.

A client with severe osteoarthritis and decreased mobility is transferred to an assisted living facility. The nurse notices that the client smells of alcohol, exhibits an unsteady gait and has six wine bottles in the trash. The client tells the nurse, "Those are my other pain medicines" Which of the following statements by the nurse are most appropriate? Select all that apply. 1. I didn't realize that your pain was not being managed with your current medications 2. It is important for me to know how many bottles of wine you drank this week. 3. Im worried about the amount of wine you are drinking and its effect on your balance. 4. How are you getting all this wine? 5. I am calling your doctor to have all of us to talk about better pain control without the wine.

1, 2, 3, 5

A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply 1. Excessive alcohol use 2. Gallstones 3. Abdominal trauma 4. HTN 5. Hyperlipidemia with excessive triglycerides 6. Hypothyroidism

1, 2, 3, 5

Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply 1. Accepting the client while not arguing with the delusion 2. Focusing on the feelings or meaning of the delusion 3. Focusing on events and topics based in reality 4. Confronting the client's beliefs 5. Interacting with the client only when the client is based in reality

1, 2, 3. For the client with grandiose, the nurse should accept the client but not argue with the delusion to build trust and the client's self-esteem. Focusing on the underlying feeling or meaning of the delusion helps to meet the client's needs. Focusing on events and topic based in reality distracts the client from delusional thinking. Confronting the client's delusions or beliefs can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-esteem. Interacting with the client only when based in reality ignores the client's needs and therapeutic nursing interventions.

The nurse is preparing a teaching plan for a 45 year old client recently diagnosed with type 2 DM. What is the first step in this process? 1. Establish goals 2. Choose video materials and brochures 3. Assess the client's learning needs 4. Set priorities

3