SATA NCLEX Sample

10. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. 1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. 2. Activity intolerance related to increased cardiac output. 3. Decreased cardiac output related to structural and functional changes. 4. Impaired gas exchange related to decreased sympathetic nervous system activity.

10. Answer: 1 and 3. HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.

6. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply. 1. "I will need to dispose of my old clothing when I return home."2. "I should always cover my mouth and nose when sneezing."3. "It is important that I isolate myself from family when possible."4. "I should use paper tissues to cough in and dispose of them properly."5. "I can use regular plate and utensils whenever I eat."

6. Answer: 2, 4, 5.

9. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 5. Decreased oral sodium intake 6. Medication that is antagonistic to antidiuretic hormone (ADH)

9. Answers: 1, 2, 4 and 6.Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal.

9. A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 3. Maintaining a low-potassium diet 4. Monitoring extremities for edema 5. Maintaining a low-sodium diet

9. Answers: 1, 2, 4, and 5.The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

10. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

10. Answer: 2The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.

10. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Checking the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

10. Answers: 1, 2, and 4.A focused data collection process focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

10. The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply: 1. Presence of cardiac pain. 2. Medications taken before hospitalizations. 3. Presence of jugular vein distention. 4. Heart sounds and apical rate. 5. Presence of diaphoresis. 6. History of difficulty breathing.

10. Answers: 1, 3, 4, and 5. A focussed cardiac assessment is directed towards assessing physiologic symptoms (cardiac pain, JVD, heart sounds and rate, and presence of diaphoresis) that provide immediate information regarding the clients condition, which is appropriate for the nurse to do at the beginning of each shift. After the physiological parameters have been evaluated the nurse can determine history of SOB and meds.

10. Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply. 1. "Take the medication at bedtime." 2. "Take the medication with each meal." 3. "Take the medication on an empty stomach." 4. "Side effects include abdominal bloating and flatus." 5. "Take some form of glucose if hypoglycemia occurs." 6. "Report symptoms such as shortness of breath or tiredness."

10. Answers: 2, 4, 5, and 6.The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.

11. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply. 1. Verify patency of the line by the presence of a blood return at regular intervals. 2. Inspect the insertion site for swelling, erythema, or drainage. 3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 4. If unable to aspirate blood, reposition the client and encourage the client to cough. 5. Contact the health care provider about verifying placement if the status is questionable.

11. Answer: 1, 2, 4, 5. A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

11. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe? 1. Respirations that cease for several seconds 2. Respirations that are regular but abnormally slow 3. Respirations that are labored and increased in depth and rate 4. Respirations that are abnormally deep, regular, and increased in rate

11. Answer: 4.Kussmaul's respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

11. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply. 1. Skin 2. Kissing 3. Inhalation 4. Gastrointestinal 5. Direct contact with an infected individual 6. Sexual contact with an infected individual

11. Answers: 1, 3, and 4.Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person.

11. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Contact the health care provider if the child complains of numbness or tingling in the extremity. 6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

11. Answers: 2, 5, and 6.While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of

12. A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client's history? Select all that apply. 1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. Self-destructive behavior

12. Answer: 1, 2, 5.

12. A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. "I will give my child cough syrup if a cough develops." 2. "During an attack, I will take my child to a cool location." 3. "I will give acetaminophen (Tylenol) if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

12. Answer: 1.Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

12. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following? 1. "We will be sure to not leave hot liquids unattended." 2. "I guess my child needs to understand what the word 'hot' means." 3. "We will be sure that our child stays in his room when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so that our child can't get into the kitchen."

12. Answer: 1.Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. Options 2, 3, and 4 do not reflect an adequate understanding of the principles of safety.

12. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. 1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities of daily living. 5. Encourage coughing and deep breathing. 6. Educate regarding symptoms of retinal detachment.

12. Answers: 1, 2, 3, 4, and 6. An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

13. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply. 1. The client functions well in other areas of his life. 2. The degree of aggressiveness is out of proportion to the stressor. 3. The violent behavior is most often justified by the stressor. 4. The client has a history of parental alcoholism and chaotic, abusive family life.5. The client has no remorse about the inability to control his anger.

13. Answer: 1, 2, 4. A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.

13. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? 1. A task approach method is used to provide care to clients.2. Managed care concepts and tools are used when providing client care.3. Nursing staff are led by a nurse when providing care to a group of clients.4. A single registered nurse is responsible for providing nursing care to a group of clients.

13. Answer: 3.In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

13. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

13. Answer: 4.Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranesand intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.

13. The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply. 1. Diuretics 2. Anticoagulants 3. Anticholinergics 4. Cardiac glycosides 5. Phosphodiesterase (PDE) inhibitors 6. Angiotensin-converting enzyme (ACE) inhibitors

13. Answers: 1, 4, 5, and 6.Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

14. The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response? 1. When the toddler weighs 20 lb and is 1 year old 2. When the weight of the toddler is more than 40 lb 3. The seat should not be placed in a face-forward position unless there are safety locks in the car. 4. The seat should never be placed in a face-forward position because of the risk of the child unbuckling the harness.

14. Answer: 1.The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat, but it is generally at a body weight of 9 kg (20 lb) and an age of 1 year. Options 2, 3, and 4 are incorrect.

14. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization

14. Answer: 2.The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. Theclient who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

14. Which of the following nursing interventions are written correctly? (Select all that apply.) 1. Apply continuous passive motion machine during day. 2. Perform neurovascular checks. 3. Elevate head of bed 30 degrees before meals. 4. Change dressing once a shift.

14. Answer: 3. It is specific in what to do and when.

14. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications? 1. A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. A 10-year-old female client with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches

14. Answer: 3.Children should not be given herbal therapies, especially in the home and without professionalsupervision. There are no general contraindications for the clients described in options 1, 2, and 4.

15. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client's outflow is less than the inflow. Select actions that the nurse should take. 1. Place the client in good body alignment2. Check the level of the drainage bag3. Contact the physician

15. Answer: 1, 2, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

15. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

15. Answer: 4.If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery.

15. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim. Select all that apply. 1. Failure to replace body fluids 2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 5. Excessive bumetanide administration 6. Lack of follow-up nursing actions

15. Answers: 2, 3, 4, and 6.To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

15. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply. 1. Call a code blue. 2. Notify the registered nurse. 3. Place the infant in a prone position. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids .6. Prepare to administer 100% oxygen by face mask.

15. Answers: 2, 4, 5, and 6.The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

16. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply. 1. Excess Fluid Volume2. Imbalanced Nutrition; Less than Body Requirements3. Activity Intolerance4. Impaired Gas Exchange5. Pain.

16. Answer: 1, 2, 3. Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

16. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client on renal dialysis 4. A client with diabetes mellitus 5. A 29-year-old woman with pneumonia 6. A client with congestive heart failure

16. Answers: 1, 2, 3, and 6.Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

16. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. 1. Monitor the client's ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client's ability to move the extremities. 5. Inspect the puncture site for swelling, redness, and drainage. 6. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

16. Answers: 1, 2, 4, and 5.Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider's prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage, and monitors the client's ability to void and move the extremities.

16. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply. 1. Oliguria 2. Seizures 3. Contractions 4. Proteinuria 3+ 5. Muscle cramps 6. Blood pressure 168/116 mm Hg

16. Answers: 1, 4, and 6.Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

17. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1. Head tilt 2. Vomiting 3. Polydipsia 4. Lethargy 5. Increased appetite 6. Increased pulse

17. Answer: 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

17. An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure.2. Try calling the client's spouse to obtain telephone consent before the surgical procedure.3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent.

17. Answer: 4.Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.

17. A nurse is monitoring a client with Graves' disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply. 1. Bradycardia 2. Fever 3. Sweating 4. Agitation 5. Pallor

17. Answers: 2, 3, and 4.Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

17. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients? 1. A client complaining of muscle aches, a headache, and malaise 2. A client who twisted her ankle when she fell while rollerblading 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

17. Answers: 4.In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as non urgent, and they are the number 3priority.

18. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication6. Place the client in a supine position with legs elevated

18. Answer: 1, 2, 4, 5. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.

18. When caring for a 3-year-old child, the nurse should provide which toy for this child? 1. A puzzle 2. A wagon 3. A golf set 4. A farm set

18. Answer: 2.Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.

18. A nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

18. Answers: 1Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility in which the client is receiving care.

18. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply. 1. Severely anxious client 2. Pneumonia client 3. Diabetic mellitus client 4. Malnourished client 5. Asthma client 6. Renal failure client

18. Answers: 3, 4, and 6.Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.

19. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply. 1. "If I limit my fluid intake I will not have to empty my ostomy pouch as often." 2. "I can place an aspirin tablet in my pouch to decrease odor." 3. "I can usually keep my ostomy pouch on for 3 to 7 days before changing it." 4. "I must use a skin barrier to protect my skin from urine." 5. "I should empty my ostomy pouch of urine when it is full."

19. Answer: 3, 4. The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

19. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs 3. To place an eye shield on the surgical eye at bedtime 4. That episodes of sudden severe pain in the eye is expected 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort

19. Answers: 1, 3, 5, and 6.After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

19. When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply. 1. Increased heart rate2. Decline in visual acuity3. Decreased respiratory rate4. Decline in long-term memory5. Increased susceptibility to urinary tract infections6. Increased incidence of awakening after sleep onset

19. Answers: 2, 5, and 6.Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

19. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply. 1. "I enjoy exercising but I need to be careful." 2. "I need to pace my activities throughout the day." 3. "I need to limit playing football to only the weekends." 4. "I should gauge my activity level by my energy level." 5. "I should exercise in the evening to encourage a good sleep pattern."

19. Answers: 3 and 5.The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

8. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany 4. Stimulate the release of parathyroid hormone.

8. Answer: 3.

2. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. 1. Weight loss. 2. Increased clotting time. 3. Hypertension. 4. Headaches.

2. Answer: 2, 3, and 4 Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.

2. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis? 1. Identifying the client's ability to function 2. Identifying the client's potential for self-harm 3. Inquiring about the client's feelings that may affect coping 4. Inquiring about the client's perception of the cause of the neighbor's death

2. Answer: 3.The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

2. The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply. 1. "Increase water intake." 2. "Increase calcium intake." 3. "Take pulse rate each day." 4. "Weigh at the same time each day." 5. "Palpitations may occur early in therapy." 6. "Be careful when rising from sitting to standing."

2. Answers: 3, 4, 5, and 6.Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

2. A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply. 1. Diazepam (Valium) 2. Alprazolam (Xanax) 3. Gabapentin (Neurontin) 4. Ethosuximide (Zarontin) 5. Carbamazepine (Tegretol) 6. Methylphenidate (Ritalin)

2. Answers: 3, 4, and 5. Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. Diazepam is a medication that is prescribed to halt tonic-clonic episodes, and methylphenidate is a medication used to treat attention deficit hyperactivity disorder. Both of these medications are not suitable for long-term control of a seizure condition. Alprazolam is a medication used to treat anxiety.

20. Which data indicates to the nurse that a client may be experiencing ineffective coping? 1. Constantly neglects personal grooming2. Visits her husband's grave once a month3. Visits the senior citizens' center once a month4. Frequently looks at snapshots of her husband and family

20. Answer: 1Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.

20. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

20. Answers: 1, 2, 3, and 4.Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

20. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs 3. To place an eye shield on the surgical eye at bedtime 4. That episodes of sudden severe pain in the eye is expected 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort

20. Answers: 1, 3, 5, and 6.After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

20. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. 1. Uterine enlargement 2. Fetal heart rate detected by nonelectric device 3. Outline of the fetus via radiography or ultrasound 4. Chadwick's sign 5. Braxton Hicks contractions6. Ballottement

20. Answers: 1, 4, 5, and 6. The probable signs of pregnancy include: Uterine Enlargement Hegar's sign or softening and thinning of the uterine segment that occurs at week 6. Goodell's sign or softening of the cervix that occurs at the beginning of the 2nd month Chadwick's sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. Ballottement or rebounding of the fetus against the examiner's fingers of palpation Braxton-Hicks contractions Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG Active fetal movement palpable by the examiners Outline of the fetus via radiography or ultrasound

21. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? 1. Elevated blood pressure2. Negative urinary protein3. Facial edema4. Increased respirations

21. Answer: 1 and 3. The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

22. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. 1. Monitor maternal vital signs every 2 hours 2. Notify the physician if respirations are less than 18 per minute. 3. Monitor renal function and cardiac function closely 4. Keep calcium gluconate on hand in case of a magnesium sulfate overdose 5. Monitor deep tendon reflexes hourly 6. Monitor I and O's hourly 7. Notify the physician if urinary output is less than 30 ml per hour.

22. Answers: 3, 4, 5, 6, and 7. When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

23. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply. 1. Reflects electrical impulse beginning at the SA node 2. Indicated electrical impulse beginning at the AV node 3. Reflects atrial muscle depolarization 4. Identifies ventricular muscle depolarization 5. Has duration of normally 0.11 seconds or less.

23. Answer: 1, 3, 5. In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

8. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply: 1. Elevate the HOB.2. Decrease intake of caffeine.3. Discuss strategies for weight loss if overweight.4. Increase fluid intake with meals.5. Take ranitidine (Zantac) at hs.6. Eat a bedtime snack of milk and protein.

8. Answers: 1, 2, 3, 5. This will all help neutralize stomach acid. Drinking lots with meals and eating before bed will exacerbate the problem

24. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply. 1. Verify patency of the line by the presence of a blood return at regular intervals. 2. Inspect the insertion site for swelling, erythema, or drainage. 3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 4. If unable to aspirate blood, reposition the client and encourage the client to cough. 5. Contact the health care provider about verifying placement if the status is questionable.

24. Answer: 1, 2, 4, 5. A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

25. To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.) 1. Drinking a glass of wine just before retiring to bed 2. Eating a large meal 1 hour before bedtime 3. Consuming a small glass of warm milk at bedtime 4. Performing mild exercises 30 minutes before going to bed

25. Answer: 3. A small glass of milk relaxes the body and promotes sleep.

26. The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply): 1. Extended time to fall asleep 2. Falling asleep at inappropriate times 3. Difficulty staying asleep 4. Feeling tired after a night's sleep

26. Answer: 1, 3, and 4. These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.

27. The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply): 1. Prone 2. Side-lying 3. Supine 4. Fowler's

27. Answer: 2 and 3. Research demonstrate that the occurrence of SIDS is reduced with these two positions.

28. A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply: 1. Chronic stress 2. Severe anxiety 3. Generalized pain 4. Excessive caffeine 5. Chronic depression 6. Environmental noise

28. Answer: 1, 4, and 6. Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia.

29. Select all that apply to the use of barbiturates in treating insomnia: 1. Barbiturates deprive people of NREM sleep2. Barbiturates deprive people of REM sleep3. When the barbiturates are discontinued, the NREM sleep increases.4. When the barbiturates are discontinued, the REM sleep increases.5. Nightmares are often an adverse effect when discontinuing barbiturates.

29. Answer: 2, 4, and 5. Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.

3. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. 1. The inhaler is held upright. 2. Head is tilted down while inhaling the medication 3. Client waits 5 minutes between puffs. 4. Mouth is rinsed with water following administration 5. Client lies supine for 15 minutes following administration.

3. Answer: 1 and 4.

3. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing through the sleeve, followed by the client's arm

3. Answer: 2.The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.

3. A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate? 1. Enteric precautions 2. Neutropenic precautions 3. No precautions are required as long as antibiotics have been started. 4. Isolation precautions for at least 24 hours after the initiation of antibiotics

3. Answer: 4. Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun and maintained for at least 24 hours after antibiotics are given. Options 1, 2, and 3 are incorrect.

3. A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply. 1. Tuck pant legs into socks. 2. Wear closed shoes when hiking. 3. Apply insect repellent containing DEET. 4. Cover the ground with a blanket when sitting. 5. Remove attached ticks by grasping with thumb and forefinger. 6. Wear long sleeves and long pants in dark colors when in high-risk areas.

3. Answers: 1, 2, 3, and 4.Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

2. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply: 1. Position the client directly on the trochanter when side lying. 2. Avoid use of donut type devices 3. Massage bony prominences. 4. Elevate the HOB no more than 30 degrees when possible. 5. When the client is side lying, use the 30 degree lateral inclined position. 6. Avoid uninterrupted sitting in a chair or wheelchair.

3. Answers: 1, 5, 6. Medications must be evaluated in terms of their potential for increasing the intraocular pressure. Ophthalmic drops are often prescribed for glaucoma and clients should know how to administer them correctly. Diabetes is a risk factor and its mgmt is important in helping slow POAG. An increase in intraocular pressure could cause further damage to a patient with POAG. The questions states the client is already diagnosed, POAG is painless and not correlated to BP.

3. The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply: 1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. 2. Determine whether the client has any sudden loss of vision accompanied by pain. 3. Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision. 4. Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes.

3. Answers: 1, 5, 6. Medications must be evaluated in terms of their potential for increasing the intraocular pressure. Ophthalmic drops are often prescribed for glaucoma and clients should know how to administer them correctly. Diabetes is a risk factor and its mgmt is important in helping slow POAG. An increase in intraocular pressure could cause further damage to a patient with POAG. The questions states the client is already diagnosed, POAG is painless and not correlated to BP.

30. Select all that apply that is appropriate when there is a benzodiazepine overdose: 1. Administration of syrup of ipecac 2. Gastric lavage 3. Activated charcoal and a saline cathartic 4. Hemodialysis 5. Administration of Flumazenil

30. Answer: 2, 3, and 5. If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.

4. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client on a ventilator 2. A client in skeletal traction 3. A postoperative client preparing for discharge 4. A client admitted on the previous shift who has a diagnosis of gastroenteritis

4. Answer: 1.The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.

4. A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply. 1. Monitor intake and output. 2. Monitor vital signs. 3. Maintain sodium-reduced diet. 4. Monitor electrolyte levels. 5. Increase water intake orally.6. Administer sodium replacements.

4. Answers: 1, 2, 3, 4, and 5. Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

4. A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply. 1. Protect the stoma from water. 2. Soaps should be avoided near the stoma. 3. Wash the stoma daily using a washcloth. 4. Use diluted alcohol on the stoma to clean it. 5. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.6. Use soft tissues to clean any secretions that accumulate around the stoma.

4. Answers: 1, 2, 3, and 5.The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

4. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client's teaching plan? Select all that apply. 1. Hearing loss 2. Visual disturbance 3. Headache 4. Orthopnea5. Gout6. Weight loss

4. Answers: 2, 3, 4 and 5. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

4. A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply: 1. Warming the dialysate 2. Too rapid installation 3. Infiltration of the solution into the bloodstream 4. Accumulation of dialysate solution under the diaphragm 5. Too rapid outflow of the dialysate.

4. Answers: 2,4. Rapid outflow doesn't cause pain, warming helps with discomfort and the dialysate does not infiltrate the circulation.

5. A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with a colostomy 3. The client with decreased kidney function 4. The client with congestive heart failure (CHF)

5. Answer 2.Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.

5. Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest pain.4. Presence of peripheral edema5. Color of nail beds

5. Answer: 1, 3, 5. A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply.

5. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular

5. Answer: 2.The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments thatwould be the priority.

5. A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse's appropriate action is to: 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

5. Answer: 4.The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

5. The nurse is evaluating a client's response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply: 1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 2. Cr decreases from 1.6 to 0.8 mg/dL 3.Hgb increases from 10-12 g/dL 4. WBC increase from 5000 to 8000/mm^3 5. BUN decreases from 110 to 90 mg/dL

5. Answers: 1, 2, 5. Primary action of hemodialysis is to clear nitrogenous waste products.

6. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway

6. Answer: 1, 2, 3, and 4.A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device.

8. A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 3. Maintaining a low-potassium diet 4. Monitoring extremities for edema 5. Maintaining a low-sodium diet

8. Answers: 1, 2, 4, and 5.The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

6. A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply. 1. Jewelry will need to be removed. 2. An informed consent will need to be signed. 3. A trained x-ray technician performs the procedure. 4. The procedure will take approximately 45 minutes. 5. A liquid diet can be consumed on the day of the procedure. 6. Solid food intake needs to be restricted only on the day of the procedure.

6. Answer: 1, 2, and 4.Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is told that the procedure takes about 45 minutes. An informed consent is required because the procedure is invasive and is therefore performed by the health care provider. The client will need to remove jewelry and metal objects from the chest area. The client is also told that pretest medications may be prescribed for relaxation.

6. The nurse understands that the following clinical findings are indications for dialysis. Select all that apply: 1. Volume overload 2. BUN 18 mg/dL 3. K 5.2 mEq/L 4. Decreased creatinine clearance. 5. Metabolic acidosis 6. Cr 5.0 mg/dL

6. Answers: 1, 3, 5, 6. Indications for dialysis include volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (normally 10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along with decreased urinary creatinine clearance. The K level is hyperkalemic, the BUN is normal.

6. A nurse is told in report that a client has a positive Chvostek's sign. What other data would the nurse expect to find on data collection? Select all that apply. 1. Coma 2. Tetany 3. Diarrhea 4. Possible seizure activity 5. Hypoactive bowel sounds 6. Positive Trousseau's sign

6. Answers: 2, 3, 4 and 6.A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.

7. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply. 1. Thirst 2. Palpitations 3. Diaphoresis 4. Slurred speech 5. Hyperventilation

7. Answer: 2, 3, 4. Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed.

7. A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is: 1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs of the client without consent 4. Telling the client that he or she cannot leave the hospital

7. Answer: 3.Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.

7. The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply: 1. Decrease in pulse rate in affected leg. 2. Paresthesia distal to area of injury. 3. Toes on affected leg cool to touch and edematous. 4. Complaints that pins are hurting. 5. Complaints of leg pain unrelieved by analgesics or repositioning. 6. Client angry and calling loudly to the nurse every ten minutes.

7. Answers: 2, 3, 5. Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture the will be edema, a decrease in rate is not an indication of pressure, a decrease in pulse strength is. Anger can be due to immobility, and the pins do not usually cause pain, but this may be a sign of infection.

7. A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply. 1. Ataxia 2. Sedation 3. Constipation 4. Bleeding gums 5. Hyperglycemia 6. Decreased platelet count

7. Answers: 3, 4, 5, and 6.Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily, and blood glucose levels can elevate when taking phenytoin. Sedation is a side effect of barbiturates, not phenytoin. Ataxia is a side effect of benzodiazepines.

7. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply. 1. On the left side 2. With the neck flexed 3. Supine on the left side 4. With extreme hip flexion 5. In a semi-Fowler's position 6. With the head in a midline position

7. Answers: 5 and 6.Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents. 8. Answer: 3. 9. Answer: 3.Goggles are worn to protect the mucous membranes of the eye during interventions that may producesplashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are notnecessary. 10. Answer: 2The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis. 11. Answer: 4.Kussmaul's respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease

8. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply: 1. Sweating 2. Low PCO2 3. Retinopathy 4. Acetone breath 5. Elevated serum bicarbonate

8. Answer: 2, 4. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis.

8. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 5. Decreased oral sodium intake 6. Medication that is antagonistic to antidiuretic hormone (ADH)

8. Answers: 1, 2, 4, and 6.Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADHsynthesis and release processes return to normal.

9. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply. 1. Assessing the client's bowel sounds 2. Providing skin care following bowel movements 3. Evaluating the client's response to antidiarrheal medications 4. Maintaining intake and output records 5. Obtaining the client's weight.

9. Answer: 2, 4, and 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

9. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? 1. Gloves and a gown 2. Gloves and goggles 3. Gloves, a gown, and goggles 4. Gloves, a gown, and shoe protectors

9. Answer: 3.Goggles are worn to protect the mucous membranes of the eye during interventions that may producesplashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are notnecessary.

9. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply: 1. Verify consent has been signed. 2. Explain procedure to client. 3. Provide clear liquid, no caffeine diet. 4. Evaluate peripheral pulses. 5. Obtain a 12 lead ECG 6. Obtain history of shellfish allergy.

9. Answers: 1, 2, 5, and 6. In cardiac catheterization contrast dye is injected into the coronary artery and provides info on patency. Informed consent must be signed prior to any invasive procedure. The physician is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO 6-18 hours prior. An ECG would be done, butmeasures electrical not blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.

1. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. 1. Partial thromboplastin time. 2. Prothrombin time. 3. Platelet count. 4. Hemoglobin 5. Complete Blood Count 6. White Blood Cell Count

Answers and Rationale 1. Answer: 1, 2, and 3 Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation.

NCLEX SATA 2 1. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply. 1. Restrict all visitors.2. Place the child on a low-bacteria diet.3. Change dressings using sterile technique.4. Encourage the consumption of fresh fruits and vegetables.5. Perform meticulous hand washing before caring for the child.6. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.

Answers and Rationale 1. Answer: 2, 3, and 5. For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

NCLEX SATA 5 1. The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply: 1. Use active listening skills to seek information from the client. 2. Encourage the client to describe the problem as she sees it 3. Ask the client to tell you exactly what she thinks is happening. 4. Tell the client that she is delusional and you can help her. 5. Explain to the client that most people are not investigated by the CIA. 6. Reassure the client that you are not with the CIA.

Answers and Rationale 1. Answers: 1,2,3. The client is displaying paranoid behaviours, which necessitates a matter of fact approach that is nonjudgmental and accepting the client's statements and show the nurses willingness to actively listen. The last three do not contribute to a therapeutic nurse client relationship.

NCLEX SATA 4 1. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply. 1. Cola is acceptable to drink on the day of the test. 2. Tea and coffee are restricted on the day of the test. 3. The test will take between 45 minutes and 2 hours. 4. The hair should be washed the evening before the test. 5. All medications need to be withheld on the day of the test. 6. A nothing-by-mouth (NPO) status is required on the day of the test.

Answers and Rationale 1. Answers: 2, 3, and 4.Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.

NCLEX SATA 3 1. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply. 1. Scant mucus 2. Early onset cough 3. Marked weight loss 4. Purulent mucus production5. Mild episodes of dyspnea

Answers and Rationale 1. Answers: 2, 4, and 5.Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.