Transitions Study Questions

A client reports difficulty falling asleep at night. Which activity will the nurse recommend to this client? (Select all that apply.) - 1. Eat a heavy meal within 2 hours of bedtime. - 2. Have a glass of wine 30 minutes before bedtime. - 3. Arise at a specific hour every morning. - 4. Exercise 1 hour before bedtime. - 5. Drink warm milk before bedtime. - 6. Take a warm bath before bedtime.

- 3. Arise at a specific hour every morning. (Arising at a specific hour every morning promotes sleep by following a set schedule.) - 5. Drink warm milk before bedtime. (Warm milk promotes sleep because milk may encourage the release of serotonin, which has a calming effect.) - 6. Take a warm bath before bedtime. (A warm bath promotes sleep by helping with relaxation.)

The nurse provides care for a pediatric client diagnosed with early stage chronic kidney disease (CKD). Which assessment finding does the nurse expect?

- Polyuria (Polyuria occurs early in the condition, as the kidney becomes unable to concentrate urine. If untreated, it can cause severe dehydration.)

The nurse develops a brochure on health promotion. Which example of primary prevention health promotion does the nurse include in the brochure?

1. Attending a stress management class. (Primary prevention aimed at health promotion includes activities that may prevent the disease from developing. These activities include health education programs, immunizations, and physical and nutritional fitness activities.)

A client diagnosed with Parkinson disease (P) is experiencing a new onset of urinary incontinence. When providing about urinary incontinence, which client statement indicates additional teaching is needed?

4. "I need to remember to void every 4 to 6 hours."

Pt returns for follow-up appt after tx for renal calculi. Which instruction is most beneficial for the RN to teach the pt to prevent a recurrence of the health problem?

- "Drink at least 3000 mL of fluid a day." (prevention of renal calculi includes ingesting between 2500 - 3000 mL of fluid per day)

The nurse provides medication teaching to a client prescribed losartan. The client asks the nurse why the medication is required since lower leg swelling only occurs when standing too long. Which response will the nurse make to this client? (Select all that apply.) - 1. "It works by dilating blood vessels, which then reduces your blood pressure." - 2. " This medication helps slow and strengthen your heartbeat, and that will give you more energy." - 3. "Do you have a bathroom scale at home?" - 4. "You may feel dizzy at first when taking this medication. Get up slowly to avoid falls." - 5. This medication is prescribed with a large dose at first, and then it is tapered off as the symptoms improve." - 6. "If you are careful to elevate your legs for 30 minutes each hour, this medication will not be required. "

- 1. "It works by dilating blood vessels, which then reduces your blood pressure." (Losartan, an angiotensin II receptor blocker (ARB), causes dilation of blood vessels, decreases release of aldosterone, and increases renal excretion of sodium and water.) - 3. "Do you have a bathroom scale at home?" (Measuring daily weight is important to determine changes in fluid volume in the client diagnosed with heart failure.) - 4. "You may feel dizzy at first when taking this medication. Get up slowly to avoid falls." (Losartan lowers blood pressure and can cause orthostatic hypotension.)

The nurse teaches the parent of an infant client who is 2 months of age about the Haemophilus influenza type B (Hib) vaccine. The parent asks the nurse why the vaccine is necessary. Which response by the nurse is accurate?

- 2. "It prevents Hib disease, which can cause meningitis, brain damage, and deafness." (Before the Hib vaccine, Hib disease was the leading cause of bacterial meningitis in children younger than age 5 years. Hib disease can also cause pneumonia, sepsis, and death.)

A pt dx with multiple myeloma experiences persistent lower back pain. In which position will the nurse place the pt. ?

- In bed with HOB elevated 45 degrees & hips & knees moderately flexed. (flexing the knees relieves pressure on the sciatic nerve.)

A client receives ergocalciferol 240,000 units by mouth each day. The medication is available in 8000 units/mL. How many ounces will the nurse administer for one dose? (Do not round. Record your answer using a whole number.)

1 oz

A client has a prescription for digoxin 0.425 mg IV. The available medication supply is digoxin 500 mcg/2 mL. How much of medication will the nurse administer to deliver one dose to the client. (Round at the end of the equation. Record your answer using one decimal place.)

1.7 mL

The health care provider prescribes 900 mg of cimetidine to be infused over 24 hours. The medication mixture is 500 mL of dextrose 5% in water. The IV infusion device delivers 60 drops per milliliter. The nurse adjusts the flow rate to deliver how many drops per minute to the client? (Record your answer rounding to the nearest whole number.)

21 drops per minute

A client admitted to the cardiac care unit after a myocardial infarction develops shortness of breath, tachycardia, and a cough with frothy, pink-tinged sputum. Which breath sound will the nurse expect when assessing this client?

3. Course rales. (Course ales are expected with the pulmonary edema that accompanies a myocardial infarction.)

A client has been receiving heparin therapy for 7 days. The nurse reviews lab results and notices the client's platelet count changed from 150,000/mm° to 75,000/mm? (150 to 75 x 10º L) in 24 hours. The client reports, "My skin seems red to me." Which action by the nurse is best?

Hold the heparin dose and notify the health care provider.

The nurse provides care for a pediatric client diagnosed with early stage chronic kidney disease (CKD). Which assessment finding does the nurse expect?

Polyuria. (Polyuria occurs early in the condition, as the kidney becomes unable to concentrate urine. If untreated, it can cause severe dehydration.)

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The nurse prepares a client for a pharmacological stress test. The current time is 0900 and the test is scheduled for 1300. The client is requesting coffee with breakfast. Which statement does the nurse include when teaching the client? (Select all that apply.) - 1. "The medication used may increase your heart rate and blood pressure temporarily.' - 2. "Starting at 10 a.m., you cannot eat or drink until the stress test is completed. - 3. "Your heart rhythm will be monitored and recorded during the exam." - 4. "Notify the nurse of chest pain or extreme fatigue during the exam. - 5. Your coffee this morning can be caffeinated or decaffeinated." - 6. "the medication used mav cause nausea."

- 1. "The medication used may increase your heart rate and blood pressure temporarily.' (Dobutamine may be used during the stress test and is a synthetic sympathomimetic agent that increases HR, BP, and myocardial contractility.) - 2. "Starting at 10 a.m., you cannot eat or drink until the stress test is completed. (Clients need to be NPO for 3 hours prior to the exam.) - 3. "Your heart rhythm will be monitored and recorded during the exam." (Stress testing is combined with ECG monitoring to detect dysrhythmias.) - 4. "Notify the nurse of chest pain or extreme fatigue during the exam. (Further diagnostic testing, such as cardiac catheterization, may be warranted if the client develops chest pain during the stress test.) - 6. "the medication used mav cause nausea." (Vasodilating agents used for the stress test may cause flushing & nausea, which should subside quickly.)

The perioperative nurse is evaluating a group of clients for risk factors that may lead to postoperative complications, Which client is at high risk for developing respiratory complications following surgery? (Select all that apply.) - 1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago. - 2. A 34-year-old smoker who underwent a left ankle repair 2 days ago. - 3. A 60-year-old nonsmoker who underwent carpal tunnel surgery 3 hours ago. - 4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago. - 5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago.

- 1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago. (Aging increases the risk for respiratory complications, as mucociliary clearance ability diminishes with age. Following abdominal surgery, splinting and pain also may lead to shallow breathing, atelectasis, and decreased mucociliary clearance.) - 2. A 34-year-old smoker who underwent a left ankle repair 2 days ago. (Smoking increases the risk for postoperative complications, including respiratory problems, due to Impaired mucociliary clearance.) - 4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago. Thoracic surgery leads to a decreased ability to cough and inhale deeply and decreased mucociliary clearance. - 5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago. (Lung trauma, including trauma due to procedures or surgery, increases the risk for developing respiratory complications.)

A client diagnosed with congestive heart failure has been given instructions regarding a low-sodium diet. Which meal, if selected by the client, indicates a correct understanding of the diet plan? (Select all that apply.) - 1. A bowl of oatmeal topped with banana. - 2. Tossed salad with shredded cheese and ranch dressing. - 3. Plain yogurt with blueberries and granola. - 4. Canned tomato soup and a grilled cheese sandwich. - 5. A baked sweet potato with cinnamon.

- 1. A bowl of oatmeal topped with banana. - 3. Plain yogurt with blueberries and granola. - 5. A baked sweet potato with cinnamon.

A group of clients is identified as at risk for pressure injury. For which client does the nurse initiate pressure injury prevention measures? (Select all that apply.) - 1. A client in skeletal traction and who is diaphoretic. - 2. A client with reddened areas that blanch on both elbows. - 3. A premature neonate with nasogastric feedings. - 4. An infant who had surgical repair of an umbilical hernia. - 5. A client who has a temperature of 103°F (39.4°C). - 6. A client with urinary retention and who self-catheterizes.

- 1. A client in skeletal traction and who is diaphoretic. (The immobility imposed by skeletal traction combined with moist skin from diaphoresis puts this client at risk for a pressure injury.) 3. A premature neonate with nasogastric feedings. (A preterm neonate does not have sufficient subcutaneous fat stores and is at risk for skin breakdown. The presence of an NG tube increases the neonate's risk due to pressure from the tube and tape on delicate skin.)

The nurse provides care to a newly-admitted client who has a prescription for hand restraints. When delegating client care, the nurse assigns which activity to the unlicensed assistive personnel (UAP)?

- 1. Applying the restraints. (The nurse may delegate the application of prescribed restraints, as well as their temporary removal to allow for skin monitoring, to the UP who has been trained in the use and monitoring of restraints. The nurse is responsible for assessing the underlying cause or behavior that is the basis for restraint application, determining the appropriateness of the use of restraints, selecting the proper type of restraints, evaluating the effectiveness of the restraints, and assessing for potential complications related to their use.)

The nurse provides care to a newly-admitted client who has a prescription for hand restraints. When delegating client care, the nurse assigns which activity to the unlicensed assistive personnel (UAP)?

- 1. Applying the restraints. (The nurse may delegate the application of prescribed restraints, as well as their temporary removal to allow for skin monitoring, to the UAP who has been trained in the use and monitoring of restraints. The nurse is responsible for assessing the underlying cause or behavior that is the basis for restraint application, determining the appropriateness of the use of restraints, selecting the proper type of restraints, evaluating the effectiveness of the restraints, and assessing for potential complications related to their use.)

The nurse provides care to a female client with an indwelling urinary catheter. Which action will the nurse take to obtain a specimen for urinalysis from the client? - 1. Aspirate urine from the drainage tubing port. - 2. Use a sterile container for the specimen. - 3. Clean the perineum from front to back - 4. Detach the tubing from the drainage bag.

- 1. Aspirate urine from the drainage tubing port. (The specimen for urinalysis does not need to be sterile, but the system must remain sterile to reduce the risk of infection. Therefore, the specimen is obtained by sterile technique.)

Following a diagnosis of colon cancer, a middle-age client undergoes a colon resection procedure, which results in an ascending colostomy. Which intervention by the nurse is appropriate when providing postoperative care to the client? (Select all that apply.) - 1. Assess the stoma every 4 hours. - 2. Notify the health care provider if there is no stool drainage within 4 hours. - 3. Notify the health care provider of mild swelling at the stoma site. - 4. Provide emotional support to the client. - 5. Inform the client that medications will be prescribed to help with sexual performance.

- 1. Assess the stoma every 4 hours. (The stoma should be assessed every 4 hours for color and bleeding. Excessive bleeding and a stoma darkening in color indicate complications and should be reported to the health care provider.) - 4. Provide emotional support to the client. (Having a colostomy can be emotionally traumatic for the client. It is important for the nurse to provide emotional support regarding alterations in body image, as well as education on ostomy care as the client becomes receptive.)

The nurse provides care to a client receiving an epinephrine infusion following a cardiac arrest. Which assessment finding demonstrates that treatment is effective? (Select all that apply.) - 1. Blood pressure 130/67 mm Hg. - 2. Apical heart rate 99 beats/min. - 3. Pedal pulses +1 and weak bilaterally. - 4. Pupils constricted and equal bilaterally. - 5. Capillary refill less than 2 seconds.

- 1. Blood pressure 130/67 mm Hg. (Epinephrine is a vasopressor and is used off-label to help maintain an adequate blood pressure. A BP within normal limits indicates the treatment is effective.) - 2. Apical heart rate 99 beats/min. (Epinephrine is a vasopressor and is used off-label to help maintain an adequate heart rate and rhythm. An apical pulse within normal limits indicates the treatment is effective.) - 5. Capillary refill less than 2 seconds. (A capillary refill of less than 2 seconds indicates normal tissue perfusion and adequate cardiac output.)

A client has been prescribed IV vancomycin therapy for severe colitis. Which lab value causes the nurse to contact the health care provider (HCP) before initiating the vancomycin therapy? (Select all that apply.) - 1. Creatinine 1.7 mg/dL (129.63 umolL). - 2. WBC 22,000/mm° (22 x 10%/L). - 3. Digoxin level 1.5 ng/mL. (1.92 nmolL). - 4. BUN 46 mg/dL (16.42 mmol/L). - 5. Potassium 4 mEg/L (4 mmol/L).

- 1. Creatinine 1.7 mg/dL (129.63 umolL). - 4. BUN 46 mg/dL (16.42 mmol/L). (Vancomycin can be nephrotoxic, and an elevated BUN and/or creatinine level is reflective of nephrotoxicity. Alerting the HCP is warranted for possible dose or medication change.)

A client has been prescribed IV vancomycin therapy for severe colitis. Which lab value causes the nurse to contact the health care provider (HCP) before initiating the vancomycin therapy? (Select all that apply.) - 1. Creatinine 1.7 mg/dL (129.63 umovL). - 2. WBC 22,000/mm? (22 x 10° A.). - 3. Digoxin level 1.5 ng/mL. (1.92 nmolA). - 4. BUN 46 mo/dL. (16.42 mmolL). - 5. Potassium 4 mEg/L (4 mmolL).

- 1. Creatinine 1.7 mg/dL (129.63 umovL). (Vancomycin can be nephrotoxic, and an elevated creatinine level is reflective of nephrotoxicity. Alerting the HCP is warranted for possible dose or medication change.) - 4. BUN 46 mo/dL. (16.42 mmolL). (Vancomycin can be nephrotoxic, and an elevated BUN level is reflective of nephrotoxicity. Alerting the HP is warranted for possible dose or medication change.)

A client diagnosed with a severe sprain of the right ankle must avoid all weight-bearing on the right foot. Which demonstration by the client indicates proper use of the crutches? (Select all that apply.) - 1. Elbows are flexed 20 to 30 degrees. - 2. Touches down with the right foot. - 3. Ensures rubber tips are on both crutches. - 4. Bears weight on the armpits. - 5. Keeps crutches 14 to 16 inches out to side.

- 1. Elbows are flexed 20 to 30 degrees. - 3. Ensures rubber tips are on both crutches.

The nurse provides care for an infant client who underwent cleft palate repair. Which intervention by the nurse takes priority? - 1. Managing the infant's airway. - 2. Controlling the infant's pain. - 3. Providing incision care. - 4. Feeding the infant.

- 1. Managing the infant's airway. (Cleft palate repair places the infant at risk for airway compromise. Circulation, airway, and breathing always take priority; therefore, managing the infant's airway takes priority.)

The nurse assesses a client diagnosed with Addison disease. Which finding will the nurse expect the client to exhibit? - 1. Muscle cramps, fatigue, and hypotension. - 2. Shortness of breath, pallor, and hirsutism. - 3. Rales, maculopapular rash, and weight loss. - 4. Hypertension, peripheral edema, and petechiae.

- 1. Muscle cramps, fatigue, and hypotension. (Addison disease is characterized by hyposecretion of the adrenal hormones. The client would be expected to demonstrate symptoms of hyponatremia such as muscle cramps, fatigue, and hypotension.)

The nurse provides care for a client who has a pulmonary injury. Which clinical manifestation indicates to the nurse that the client is experiencing a tension pneumothorax?

- 1. Tracheal deviation. (Tracheal deviation toward the unaffected (i.e., uninjured) side is a late sign of tension pneumothorax. Breath sounds may be diminished or absent over the affected lung.)

The nurse provides care for a client diagnosed with Guillain-Barré syndrome. Which statement indicates to the nurse that the client's family member understands the diagnosis? (Select all that apply.) - 1. "The syndrome only lasts 1 or 2 weeks." - 2. "Intravenous immunoglobulins are often used for treatment." - 3. "The cause of the syndrome may be a virus." - 4. "This illness doesn't cause shortness of breath." - 5. "My loved one's ability to walk will be affected." - 6. "A feeding tube may be required for treatment."

- 2. "Intravenous immunoglobulins are often used for treatment." (Intravenous immunoglobulins decrease circulating antibody levels and reduce the amount of time the client is immobilized and can prevent the need for mechanical ventilation. This statement indicates correct understanding of the information presented.) - 3. "The cause of the syndrome may be a virus." (A viral infection precipitates clinical presentation in approximately 60% to 70% of cases. This statement indicates correct understanding of the information presented.) - 5. "My loved one's ability to walk will be affected." (Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. This statement indicates correct understanding of the information presented.) - 6. "A feeding tube may be required for treatment." (If the client cannot swallow because of bulbar paralysis, a gastrostomy tube may be placed to administer nutrients. This statement indicates correct understanding of the information presented)

A young adult client diagnosed with a terminal illness states, "I'm feeling a lot better than I did last week. I think the doctor is wrong about my diagnosis." Based on the stages of grief described by Kübler-Ross, the nurse recognizes the client is experiencing which stage? - Acceptance - Denial - Anger - Bargaining

- 2. Denial. (The client's statement is reflective of the denial stage, during which the individual is in disbelief of the situation and may request a second opinion.)

The nurse on the medical unit reviews laboratory results on four clients. Which result causes the nurse to notify the health care provider?

- 2. Digoxin level 2.5 ng/mL (3.2 mol/L) for a client diagnosed with heart failure. (The normal therapeutic level of digoxin in the blood is between 0.5 and 2 ng/mL. (0.6 to 2.6 molL). The client with a digoxin level of 2.5 ng/mL. (3.2 nmo/L) has digoxin toxicity, and this should be reported to the health care provider. Digoxin is a cardiac glycoside and a positive inotrope.)

The nurse provides care for a client who underwent bowel resection surgery 2 days ago. The nurse has administered IV morphine for breakthrough pain, as well as a scheduled dose of oral hydrocodone-acetaminophen. The client states that the pain is currently a 3/10. Which action is most appropriate for the nurse to take at this time?

- 2. Discuss implementation of non-pharmacological pain relief measures. (Once pain following a major procedure is controlled, non-pharmacologic measures (e.g., heat/cold therapy, relaxation breathing, meditation) can be implemented to complement the pain medication regimen to improve client comfort.)

The nurse assesses hypotension, tachycardia, and crackles in the lung bases of a client with an acute inferior wall myocardial infarction. Which action does the nurse take first?

- 2. Notify the health care provider. (The client exhibits signs of heart failure, a complication of acute myocardial infarction. The nurse should notify the health care provider of the change in the client's condition to prevent a delay in treatment.)

The nurse teaches a client diagnosed with polycystic kidney disease (PK) about the treatment plan. Which client statement indicates to the nurse that further teaching is necessary?

- 3. "I need to follow a high-sodium diet." (Individuals with this disease are taught to decrease, not increase, sodium intake. This statement indicates the need for further education.)

The nurse teaches a client about measures to combat seasonal affective disorder (SAD). Which statement by the client indicates to the nurse that teaching was effective? - 1. "I will make sure to get eyeglasses that have ultraviolet filters." - 2. "I will sit within 3 feet of artificial light for 30 minutes a day." - 3. "I will continue phototherapy until Spring." - 4. "I will only use phototherapy during daytime hours."

- 3. "I will continue phototherapy until Spring." (The client diagnosed with seasonal affective disorder should use phototherapy beginning in the Fall and continue use until Spring.)

A client diagnosed with pelvic inflammatory disease (PID) has a prescription for intravenous tetracycline. Which intervention should the nurse include in the client's plan of care? (Select all that apply.) - 1. Encourage the client to take calcium supplements. - 2. Advise the client to discontinue breastfeeding. - 3. Ask the dates of the client's last menstrual period. - 4. Assess the IV catheter site frequently. - 5. Instruct the client to use barrier - 6. Instruct the client to use sunscreen.

- 3. Ask the dates of the client's last menstrual period. - 4. Assess the IV catheter site frequently. - 5. Instruct the client to use barrier - 6. Instruct the client to use sunscreen.

The nurse provides care to an older adult client with partial- and full-thickness burns over 75% of the body. Which assessment indicates to the nurse the client is developing shock? - 1. Epigastric pain and seizures. - 2. Widening pulse pressure and bradycardia. - 3. Cool, clammy skin and tachypnea. - Kussmaul respirations and lethargy.

- 3. Cool, clammy skin and tachypnea. (The body responds to early hypovolemic shock by adrenergic stimulation. Vasoconstriction compensates for the loss of fluid as blood is shunted from the periphery to vital organs such as the heart and lungs; the result is cool, clammy skin and a rapid respiratory rate.)

The nurse assesses the skin of an older adult client. Which assessment finding indicates to the nurse that the client is experiencing a potential complication?

- 3. Crusting (Crusting on the skin indicates a potential complication such as infection, allergic reaction, or injury.)

The nurse assesses a client for stress-related risk factors. Which factor in the client's recent history places the client at the greatest risk for a stress-related disorder based on the Social Readjustment Rating Scale?

- 3. Death of a spouse (According to the Social Readjustment Rating Scale, death of a spouse ranks as the highest risk factor for stress-related disorder.)

The nurse provides care for a client diagnosed with hyperthyroidism. Which intervention does the nurse include in the plan of care for this client? - 1. Extra blankets. - 2. Small, frequent meals. - 3. Quiet environment. - 4. High-fiber diet.

- 3. Quiet environment. (This client is in a hypermetabolic state, so a physically and mentally restful environment is helpful.)

The antepartum nurse is planning care for several clients who are waiting to be seen for a prenatal examination. Which client does the nurse assess first? - 1. The client who reports nosebleeds at 8 weeks gestation. - 2. The client who reports vulva and rectal varicosities at 16 weeks gestation. - 3. The client who reports abdominal pain at 24 weeks gestation. - 4. The client who reports leg cramps when reclining at 32 weeks gestation.

- 3. The client who reports abdominal pain at 24 weeks gestation. (Persistent or severe abdominal or epigastric pain could indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placenta. This client should be assessed first.)

The nurse prepares to administer subcutaneous enoxaparin to a client diagnosed with deep venous thrombosis. Which technique does the nurse implement when administering the medication? (Select all that apply.) - 1. Expels air bubble from the pre-filled syringe. - 2. Aspirates the plunger after injection. - 3. Uses a tuberculin syringe for multi-dose vials. - 4. Inserts the needle at a 35-degree angle. - 5. Rotates injection sites with each dose.

- 3. Uses a tuberculin syringe for multi-dose vials. - 5. Rotates injection sites with each dose.

An older adult client asks the nurse to explain therapeutic massage since the health care provider recommended it as treatment. Which response by the nurse is appropriate? - 1. "It decreases fluid retention." - 2. "It helps to resolve blood clots in legs." - 3. "It decreases hypertension." - 4. "It improves circulation and muscle tone."

- 4. "It improves circulation and muscle tone." (Therapeutic massage will help improve circulation and muscle tone, particularly in older adult clients.)

A client receives gentamicin 500 mg every 8 hours IV for a leg infection. The nurse touches the client's shoulder when there is no response to a greeting. The client jumps and acts startled. Which action by the nurse is most important?

- 4. Check the client for tinnitus and hearing loss. (Ototoxicity is a serious adverse effect of the aminoglycosides such as gentamicin. The client needs to be assessed for hearing loss.)

The nurse screens clients for the risk for developing pulmonary tuberculosis (TB). Which client is at risk for developing this type of TB?

- 4. Client with positive test results for the human immunodeficiency virus. (The client who is positive for the human immunodeficiency virus can be immunocompromised. The TB organism is opportunistic. This client is at a high risk for developing active TB.)

The nurse provides care for a 2-week-old client during a wellness visit. Which instruction does the nurse provide to the parents in relation to the neonate's sleep?

- 4. Do not rock the newborn to sleep. (Parents should be encouraged to place the newborn in the crib to fall asleep instead of rocking the baby to sleep.)

A client in a long-term care facility reports not getting enough sleep and wants to nap during the day. Which action by the nurse is best? - 1. Assess the client's level of pain at bedtime. - 2. Suggest the client have an alcoholic drink before going to bed. - 3. Advise the client to avoid caffeine within 4 hours of bedtime. - 4. Have the client keep a sleep diary and rate sleep quality for a week.

- 4. Have the client keep a sleep diary and rate sleep quality for a week.

The nurse provides care to a client diagnosed with severe liver disease. Which intervention is appropriate for the nurse to include in this client's plan of care? - 1. Low-sodium IV albumin. - 2. Sodium polystyrene sulfonate enemas. - 3. Sengstaken-Blakemore tube. - 4. Low-protein, high-carbohydrate diet.

- 4. Low-protein, high-carbohydrate diet. (A low-protein, high-carbohydrate diet will help reduce the risks of hepatic coma by reducing the level of ammonia that results from the breakdown of proteins.)

A client is being evaluated for a possible diagnosis of myasthenia gravis. The client is receiving an injection of IV edrophonium chloride. Which client response to this medication indicates a diagnosis of myasthenia gravis?

- 4. The client exhibits a fast and observable increase in muscle strength.

The nurse admits four clients to the labor and delivery unit. Which client does the nurse see first?

- 4.A primigravida client with baseline fetal heart tones 136 bpm with decelerations to 116 bpm independent of contractions. (This describes recurrent variable decelerations, which indicates umbilical cord compression. There is an immediate risk to the safety of the fetus.)

A client with a history of diabetes mellitus, renal insufficiency, hypertension, and coronary artery disease undergoes percutaneous transluminal coronary angioplasty (PTCA) to the right coronary artery. When the client arrives to the unit after the procedure, the nurse observes a large hematoma at the insertion site. Which action does the nurse take first?

- Apply manual pressure to the groin. (This is the priority action. Because the client is experiencing a hematoma, the nurse would want to apply manual pressure to the insertion site immediately to promote hemostasis.)

The nurse provides care for a client receiving enteral feedings via a gastrostomy tube. The nurse gives the feedings by bolus. In which order does the nurse complete the activities associated with administering the bolus feeding? (Arrange in the correct order.) - Monitor pre-albumin levels. - Ensure formula is at room temperature - Check for gastric residual volume. - Flush gastrostomy tube with 30 mL water. - Assess daily intake and output.

- Ensure formula is at room temperature - Check for gastric residual volume. - Flush gastrostomy tube with 30 mL water. - Assess daily intake and output. - Monitor pre-albumin levels. (1. Preparation of supplies occurs before beginning the feeding. Preparation includes ensuring formula is room temperature (cold formula causes gastric cramping) 2. Prior to administering a bolus feeding, check residual volume to determine if gastric emptying is delayed. For continuous feedings, check residual volume every 4 to 6 hours. 3. For bolus feedings, flush with 30 mL water before and after each feeding, and for continuous feedings, flush every 4 hours or according to institutional policy. 4. Evaluate the client's fluid balance daily or more often if indicated. 5. Check laboratory values periodically (at least monthly) to evaluate improved nutritional status. The pre-albumin level does not change on a daily basis in a meaningful way in relation to enteral feeding. NCLEX Tip: The NCLEX may not give all of the exact procedures in the answer choices. For example, we know the nurse would flush the gastrostomy tube with water before and after the feeding. However, the answer choices only give us one opportunity for flushing with water. Completing items in this order will ensure correct administration of enteral feedings.)

The nurse provides care for a client receiving enteral feedings via a gastrostomy tube. The nurse gives the feedings by bolus. In which order does the nurse complete the activities associated with administering the bolus feeding? (Please arrange in order. All options must be used.) - Assess daily intake and output. - Ensure formula is at room temperature. - Check for gastric residual volume. - Monitor pre-albumin levels. - Flush gastrostomy tube with 30 mL water.

- Ensure formula is at room temperature. - Check for gastric residual volume. - Flush gastrostomy tube with 30 mL water. - Assess daily intake and output. - Monitor pre-albumin levels. (think like a nurse: You should consider clients with feeding tubes to be at risk for complications such as aspiration, tube malpositioning or dislodgement, refeeding syndrome (see Content Refresher for more information), fluid imbalance, insertion-site infection, and agitation. When beginning feedings, monitor for feeding tolerance. You should inspect the abdomen for distention, auscultate for bowel sounds, and palpate for tenderness and rigidity. A client who reports nausea or abdominal fullness after a feeding starts may have a high gastric residual volume. It is vital that you monitor the client for abdominal distention, abdominal rigidity, abdominal pain, nausea, and vomiting on an ongoing basis. You should stop the feeding and notify the health care provider if these signs and symptoms occur.)

A client diagnosed with a head injury undergoes preparation for a lumbar puncture. Which action will the nurse take first?

- Measure pre-procedure vital signs. (A change in vital signs could indicated increasing intracranial pressure (ICP), which is a contraindication for a lumbar puncture.)

The nurse assesses a client with a pressure injury. (Arrange in order) - A blister or a wound that is pink in color. - Subcutaneous fat visible. - Undermining of the adjacent tissue with exposed bone. - Nonblanchable erythema. - Depth obscured by slough and eschar.

- Nonblanchable erythema. - A blister or a wound that is pink in color. - Subcutaneous fat visible. - Depth obscured by slough and eschar. - Undermining of the adjacent tissue with exposed bone.

The nurse admits an older adult client diagnosed in the early stages in Alzheimer disease. The nurse will place the client on fall precautions for which expected signs?

- Restlessness and pacing. (The symptoms of early-stage Alzheimer disease include recent memory loss and changes in motor activity, such as continuous pacing, wandering, and restlessness.)

A client is admitted to the medical unit. The nurse must obtain information about the client's prescribed and over-the-counter medications. The client has decreased hearing. How will the nurse perform the medication reconciliation during the hospital admission? (Please arrange in order. All options must be used.) - Verify dose, frequency, route, and last date/time each medication was taken. - Face the client and begin speaking at a normal or slightly slower pace. - Set aside uninterrupted time to obtain information. - Verify the client's identity. - File the medication reconciliation for the health care provider to review. - From the medication list, ask which medications the client is/is not taking.

- Set aside uninterrupted time to obtain information. - Face the client and begin speaking at a normal or slightly slower pace. - Verify the client's identity. - From the medication list, ask which medications the client is/is not taking. - Verify dose, frequency, route, and last date/time each medication was taken. - File the medication reconciliation for the health care provider to review.

The school nurse teaches a group of school-age and adolescent clients about menstruation with a discussion about toxic shock syndrome (TSS). Which participant statement indicates to the nurse a need for additional teaching?

1. "I use only super absorbent tampons when I am menstruating." (It has been found that super absorbent tampons increase vaginal dryness and can predispose the vaginal walls to damage. This can lead to the introduction of bacteria leading to toxic shock syndrome.)

An avid tennis player has been diagnosed with tendonitis in the right elbow. The nurse instructs the client about care statement by the client indicates an understanding of the teaching?

1. "I will ice my elbow for 20 minutes, three times a day."

The nurse provides care for a client receiving 40 drops per minute of 0.9% sodium chloride. The IV set delivers 10 drops per mL. If the nurse begins infusing 1000 mL of IV fluid at 1200, how many milliliters of fluid will be remaining at 1530? (Record your answer rounding to the nearest whole number.)

160 mL

The nurse provides care for a client who is having an anaphylactic reaction. The client is hypotensive and in respiratory distress. The nurse notes the client has swollen lips and tongue. Which intervention should the nurse perform first? - 1. Be prepared to administer intravenous (IV) epinephrine. - 2. Start an IV immediately and infuse normal saline. - 3. Apply oxygen using a high-flow, non-rebreather mask. - 4. Ensure that intubation and tracheotomy equipment is ready.

3. Apply oxygen using a high-flow, non-rebreather mask. (When a client is having an anaphylactic reaction, oxygen should immediately be applied to ensure there is adequate oxygenation helping to prevent hypoxia, dysrhythmia, shock, and cardiopulmonary arrest.)

The nurse assesses a school-age child with suspected Hodgkin lymphoma. Which finding is most characteristic of this disease?

3. Firm, painless, and movable adenopathy in the cervical area. (Firm, painless, and movable adenopathy of the cervical area is associated with this disease.)

The nurse provides care for a 7-year-old client during a wellness examination. Which factor in the child's history alerts the nurse that hyperlipidemia screening is necessary?

3. Sibling history of stroke. (If the child has a sibling with a history of stroke, screening for hyperlipidemia is recommended in children ages 2 to 8 years.)

A client will undergo surgery in 10 days. The nurse notes the client is diagnosed with adrenal insufficiency and has been taking prednisone 5 mg orally twice daily. Which prescription does the nurse expect to receive? - 1. Continue prednisone 5 mg orally twice daily before surgery. - 2. Stop prednisone 2 days prior to surgery. - 3. Reduce prednisone to 2.5 mg orally 5 days prior to surgery. -

4. Increase prednisone to 7.5 mg orally twice daily 2 days prior to surgery. (Surgery increases the demand for corticosteroids and the prednisone should be increased starting several days prior to surgery to boost the body's supply. The nurse should monitor vital signs and blood glucose, and check for infection and bleeding.)

A client receives amikacin sulfate 15 mg/kg/day IV in three divided doses. The client's weight is 176 lb. How much of the medication will the nurse administer to deliver one dose to the client. (Do not round. Record your answer using a whole number.)

400mg