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6-month-old infant is brought to the wellness clinic by parents for a routine visit. Which observation requires follow up by the nurse for evaluation of a possible developmental delay? 1.The infant cries and clings to the parent when the nurse is present. 2.The infant's weight has increased from 8 lb (3.6 kg) to 16 lb (7.3 kg) since birth. 3.The infant requires support from the parent in order to sit upright. 4.The infant abducts the extremities and fans the fingers when there is a noise.

) INCORRECT - Crying in the presence of strangers and clinging to a parent or caregiver, which are reflective of stranger anxiety, are normal findings at 5-6 months. Stranger anxiety and associated behaviors peak at approximately 7-8 months. No follow up is needed. 2) INCORRECT - The infant's weight typically doubles by 5-6 months. This observation is a normal finding. No follow up is indicated. 3) INCORRECT - To sit upright, the infant typically will require support until 7-8 months of age. Because this observation is a normal finding, follow up is not needed. 4) CORRECT— The Moro reflex, which is an involuntary startle response, is strongest during first 2 months after birth. This reflex should disappear after approximately 4 months of age. Follow up is indicated, as a persistent Moro reflex may be indicative of altered neurological development.

The industrial nurse is called to see a worker who has a radiation burn. The worker appears anxious and reports lower right, intermittent abdominal pain. Which action does the nurse take first? 1.Assess the abdominal pain. 2.Encourage the client to relax. 3.Obtain an order for pain medication. 4.Begin the decontamination process.

1) CORRECT— The client with a radiation burn does not pose a health risk to medical personnel. The nurse must assess the worker's complaint before implementing a course of action. 2) INCORRECT - Although appropriate, the priority is to assess the client's complaint. 3) INCORRECT - The nurse should first assess the client to ensure that the orders are appropriate. 4) INCORRECT - The worker does not pose a health risk to the nurse.

The school nurse educates preschool faculty and staff about hepatitis A. Which information does the nurse include in the teaching? 1.Anorexia is one of the most common symptoms of hepatitis A among children. 2.The majority of young children who contract hepatitis A will develop jaundice. 3.The hepatitis A vaccine is administered to clients beginning at 1 month of age. 4.Black, tarry stools often occur among children diagnosed with with hepatitis A.

1) CORRECT - Among pediatric clients, symptoms of hepatitis A often are flu-like in nature. Common symptoms of hepatitis A among young children include anorexia, fever, malaise, and lethargy. However, among children 6 years of age and younger, up to 70 percent of individuals who contract hepatitis A will be asymptomatic. 2) INCORRECT - Jaundice is relatively infrequent among pediatric clients who contract hepatitis A. Jaundice occurs in approximately 1 in 12 young children who experience acute viral hepatitis. 3) INCORRECT - The hepatitis A vaccine is recommended for all pediatric clients beginning at 1 year of age. The vaccination series consists of two doses of vaccine administered at least 6 months apart. 4) INCORRECT - Symptoms of hepatitis A include clay-colored stools, not black tarry stools.

Which clients are appropriate for the charge nurse to assign to the LPN/LVN on a medical unit? (Select all that apply.) 1.The client with a colostomy whose appliance is leaking. 2.The client with a serum potassium level of 2.8 mEq/L (2.8 mmol/L). 3.The client with a seizure history who is receiving gabapentin. 4.The client who needs elastic compression stockings applied. 5.The client with moderate low back pain who is restless. 6.The client with diabetes mellitus who is due a dose of insulin.

1) CORRECT - The LPN/LVN may provide care to stable clients, and colostomy care is routine care. 2) INCORRECT- This client is unstable due to hypokalemia, presenting a high risk of arrhythmia. Unstable clients are not assigned to the LPN/LVN. 3) CORRECT - An LPN/LVN may administer oral anti-seizure medications to stable clients. 4) CORRECT - An LPN/LVN may measure the client for compression stockings or sequential compression devices and apply them. 5) INCORRECT- This client's pain is not controlled and requires assessment by the nurse. 6) CORRECT - Routine insulin administration to a stable client may be provided by the LPN/LVN.

The nurse provides care for a client before surgery. Thirty minutes after administering the preoperative medication, the nurse observes the unlicensed assistive personnel (UAP) ambulate the client to the bathroom. Which action should the nurse take first? 1.Have the UAP assist the client back to bed. 2.Ask the UAP if the client had difficulty walking. 3.Determine why the UAP ambulated the client. 4.Ensure that the UAP receives the appropriate training.

1) CORRECT - The client may be sleepy after receiving preoperative medications and is at risk for falling. The client should not ambulate after receiving preoperative medications. The priority nursing action is to assist the client back to bed. 2) INCORRECT - The priority is getting the client back to bed. After ensuring that the client is safe, the nurse can ask the UAP additional questions. 3) INCORRECT - The priority is getting the client back to bed. After ensuring that the client is safe, the nurse can ask the UAP additional questions as to why the client was out of bed. 4) INCORRECT - The priority is getting the client back to bed. After ensuring that the client is safe, the nurse can determine if the UAP needs additional training.

The nurse prepares to administer the Haemophilus influenzae type b (Hib) vaccine to a 4-month-old infant. The nurse teaches the infant's parent about the vaccine. Which information does the nurse include in the teaching? 1."Monitor your child for signs of allergic reaction for a few hours after the vaccine." 2."Your child will receive 1 or 2 doses of the vaccine, depending on the vaccine used." 3."Immediately notify the health care provider of a low-grade fever." 4."This vaccine cannot be given at the same time as other vaccines."

1) CORRECT -Signs of allergic reaction to the Hib vaccine include hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine. 2) INCORRECT - Several brands of Hib vaccines are available. Depending on the brand used, the child will require 3 or 4 doses of vaccine. 3) INCORRECT - Mild adverse effects, such as low-grade fever and redness and warmth or swelling at the injection site, may occur. They are usually mild and go away on their own. Therefore, it is not necessary to notify the health care provider. 4) INCORRECT - Hib may be given at the same time as other vaccines. In fact it may be given as part of a combination vaccine.

The home health nurse visits a home occupied by two parents, their preschool-age child, and an older adult grandparent who has been living with them for 2 months. The nurse visits to assess the grandparent after treatment for a fall and broken arm. Which statement by the child most concerns the nurse? 1."My grandparent's cat got a cut on his stomach and will not come out of the corner. Can you fix it?" 2."Sometimes when I drink milk, I throw up." 3."We never go anywhere anymore since my grandparent moved in with us." 4."I want to be a doctor when I grow up and take care of hurt children and animals all over the world."

1) CORRECT — The cat's injuries and behaviors may indicate pet abuse, which can be a sign of other abuse going on in the home. This home has three categories of people at risk for abuse: child, spouse, and older adult. The grandparent was treated for injuries that might have been related to abuse. The nurse should further assess the situation for indicators of abuse. 2) INCORRECT— This may indicate a lactose allergy and requires further investigation. However, this does not pose a risk of immediate physical harm. This is not the priority concern. 3) INCORRECT— This may indicate sadness or anger on the part of the child and requires further investigation. However, this does not pose a risk of immediate physical harm. This is not the priority concern. 4) INCORRECT— This is not a concern.

The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate? 1.The client's use of language. 2.The client's insight into the depression. 3.The client's socialization history and skills. 4.The client's attitude toward medications.

1) CORRECT — The cognitive viewpoint of depression sees it as stemming from errors in thinking, which may be negative, illogical, and/or irrational. Language is used in thought as well as in speech. Speech and writing are used to express thoughts, and thereby are indicators of the client's automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions. 2) INCORRECT— The emphasis on insight is prominent in traditional psychoanalytic and psychodynamic therapies. 3) INCORRECT— The emphasis on socialization is prominent in behavioral therapies and some interpersonal psychotherapies. 4) INCORRECT— The emphasis on medications is prominent in biochemical and psychologic therapies.

The nurse manager is planning an in-service to address confidentiality issues. Which measure is appropriate for the nurse manager to include as a way to prevent confidentiality violations? 1.Keep ambulatory clients and visitors away from the nursing station as much as possible. 2.Call clients and one another by first names only. 3.Answer the telephone by saying the type of unit, but not the floor number. 4.Accompany the health care providers doing walking rounds at the bedside.

1) CORRECT — The nursing station is a center of activity in terms of in-person and telephone conversations, paperwork, and computer screens, all of which may include confidential information. Ambulatory clients, or visitors waiting for their needs to be addressed, can easily be exposed to confidential information. 2) INCORRECT— This does not prevent confidentiality violations and may be disrespectful. Some clients may prefer to be addressed by their surname. 3) INCORRECT— This is more likely to violate confidentiality by conveying the client's diagnosis to the caller (for example, if a phone is answered with "Oncology," the caller can assume the client has cancer) than if the phone were answered simply with the floor number, which is the usual procedure. 4) INCORRECT— This action is very useful in terms of interdisciplinary collaboration and, if done correctly, in terms of involving the client. However, in terms of confidentiality, it can be a problem if there is more than one client in a room and also if discussions are held outside client rooms in hallways.

The nurse makes a home visit to an older adult client who has a live-in caregiver. Which statement by the caregiver requires further assessment by the nurse? (Select all that apply.) 1."I love my client, but I feel like I am the only one who cares and it is overwhelming." 2."I felt hopeless when I lost my parent. Providing care allows me a sense of purpose." 3."I never have time to see my friends. I just crave contact outside of this house." 4."I don't have any interest in things I used to enjoy. My only purpose is providing care. " 5."I get annoyed with all the demands, but no one else is going to take care of my client."

1) CORRECT — This statement indicates a sense of being overwhelmed with a lack of support, indicating caregiver burden. The nurse should further assess the situation to offer meaningful solutions for respite. 2) INCORRECT— This statement indicates a sense of purpose and fulfillment and is not a concern. 3) CORRECT — Social isolation when caring for a sick family member may indicate caregiver burden. The nurse should further assess the situation to offer meaningful solutions for respite. 4) CORRECT — Lack of pleasure in activities indicates anhedonia, a probable sign of caregiver burden. The nurse should further assess the situation to offer meaningful solutions for respite. 5) CORRECT— Expressing annoyance and isolation in care responsibility indicates a feeling of caregiver burden. The nurse should further assess the situation to offer meaningful solutions for respite.

The nurse works on a new care area, created through the merging of two separate areas. The staff from the original care areas differ on client care approaches, which creates conflict between the two groups despite having meetings together to try to improve collaboration. Which suggestion is the most appropriate for the nurse to make to the charge nurse to reduce the amount of conflict between the two groups of staff? 1.Assign staff members to clients from both care areas. 2.Hold an in-service about the benefits of merging the two units. 3.Institute disciplinary action for staff members who talk negatively. 4.Require all staff to listen to hand-off communication on all of the clients.

1) CORRECT- Assigning staff to clients from both care areas encourages the staff to work together and experience the different types of clients to expect on the newly created care area. 2) INCORRECT - Because previous meetings have not affected change in staff behavior, more meetings are unlikely to change staff members' feelings. 3) INCORRECT - Negative talk will impact client care. Assigning staff to care for clients from both units allows the staff to better understand the needs of all the clients. 4) INCORRECT - Expecting all staff to listen to all hand-off communication is not an effective use of time. Although this might expose the staff to different client care needs, it would not be appropriate unless the staff is assigned to care for the client.

The nurse provides dietary teaching to a client with Cushing syndrome. Which client statements cause the nurse to intervene? (Select all that apply.) 1."I will follow a low-protein diet. " 2."I will follow a high-carbohydrate diet. " 3."I will follow a high-potassium diet. " 4."I will follow a low-sodium diet. " 5."I will follow a high-calorie diet. "

1) CORRECT- The client should follow a high-protein diet. 2) CORRECT- The client with Cushing syndrome should follow a low-carbohydrate diet. 3) INCORRECT - The client should follow a high-potassium diet. 4) INCORRECT - The client should follow a low-sodium diet. 5) CORRECT- The client with Cushing syndrome should follow a low-calorie diet.

The nurse in the critical care unit reviews postoperative care for a client after a supratentorial craniotomy. Which instruction is important for the nurse to communicate to the unlicensed assistive personnel (UAP)? 1."Put an ice pack on the client's eyes and a cool compress on the forehead." 2."Determine how much pain the client is experiencing on a scale of 1 to 10, and report back to me." 3."Keep the head of the bed flat, with the client lying on the back." 4."If the client starts to have a seizure, place a padded tongue blade in the mouth right away and call for help."

1) CORRECT— It is appropriate to delegate the application of heat or cold to a closed inflamed or painful area to the unlicensed assistive personnel (UAP). The client may have periorbital edema and burning after the surgery. Ice will cause vasoconstriction and decrease the edema. The cool compress is a comfort measure. 2) INCORRECT — This is an incorrect delegation, as the UAP may not perform assessments. Pain assessment must be done regularly and routinely by the nurse. 3) INCORRECT — This is an incorrect action. The head of the bed should be elevated 30 degrees to encourage venous drainage and help prevent increased intracranial pressure. The client may stay supine or be turned side to side. If the tumor removed was large, the client should be turned only to the nonoperative side in order to prevent gravity from displacing the cranial contents. 4) INCORRECT— This is an incorrect action. Tongue blades are not used for seizure management. They may cause injury to teeth, cause aspiration, or even obstruct the airway.

The nurse performs a physical assessment of a newborn who is 4 hours of age. Which finding is appropriate for the nurse to report to the health care provider (HCP)? 1.Head circumference of 40 cm. 2.Chest circumference of 32 cm. 3.Acrocyanosis noted to both feet. 4.An apical pulse rate noted at 160 beats/min.

1) CORRECT— The average head circumference is 33-35 cm. An increased circumference may indicate hydrocephalus or increased intracranial pressure. 2) INCORRECT - This is a normal finding. The chest circumference is usually less than the head circumference. 3) INCORRECT - This is a normal finding in a newborn who is only 4 hours old. 4) INCORRECT - This is within normal limits. The apical pulse rate ranges from 120-160 beats/minute.

The nurse notes that a client who delivered a newborn 18 hours ago reports swelling and pain in the right calf. Which action is appropriate for the nurse to implement? 1.Assess the client for a positive Homan sign. 2.Place the client on bed rest with the right leg elevated on a pillow. 3.Elevate both legs on a pillow and apply ice. 4.Palpate both legs to determine actual nature of pain.

1) INCORRECT - A positive Homan sign (presence of leg pain when the foot is dorsiflexed) has been thought to be an indicator of a deep vein thrombosis. A Homan sign may be absent in women who have a venous thrombosis or may be caused by a strained muscle or bruise. It is not a reliable or valid test. 2) CORRECT - Initial treatment when a deep vein thrombosis has occurred includes bed rest, with the affected leg elevated to decrease interstitial swelling and to promote venous return from the leg. 3) INCORRECT - The nurse should only elevate the affected leg and apply continuous, moist heat for relief of pain and to increase circulation. 4) INCORRECT - The leg should not be palpated since it could dislodge the clot.

The nurse receives telephone messages from clients receiving care in the outpatient clinic. Which message will the nurse return first? 1.Client with cold symptoms and an oral temperature of 103° F (39.4° C). 2.Client with a stage 2 pressure injury reporting that the dressing has come off. 3.Client with nausea who has vomited six times in the previous 24 hours. 4.Client complaining of leg pain after walking half a mile.

1) INCORRECT - An elevated temperature indicates an infection. The nurse needs to determine the underlying cause and encourage fluids. However, there is another client who requires priority assessment. 2) INCORRECT- The client with a stage 2 pressure injury whose dressing has fallen off is considered stable. 3) CORRECT- The client who is nauseated and has vomited six times in the previous 24 hours is at risk for a fluid volume deficit. The amount and character of the emesis needs to be assessed. Fluid volume deficit can impact circulation. Therefore, when using the ABCs (airway, breathing, circulation) for prioritization, the nurse returns this message first. 4) INCORRECT- Leg pain after walking is a manifestation of intermittent claudication. This client is stable.

When providing care to a group of postoperative clients, which interventions does the charge nurse delegate to the LPN/LVN? (Select all that apply.) 1.Palpating the suprapubic area of a client who has not voided in 6 hours. 2.Changing the gauze dressing for a client who had a hip pinning yesterday. 3.Teaching the client how to self-administer enoxaparin injections. 4.Titrating oxygen administration according to prescribed parameters. 5.Following up on a report of a 100.6 o F (38.1 o C) temperature in a client after an appendectomy. 6.Auscultating the abdomen of a client who is nauseated after eating broth.

1) INCORRECT - Assessing for postoperative urinary retention is done by the nurse, not the LPN/LVN. 2) CORRECT - The LPN/LVN may change dressings, so the nurse can delegate this task. 3) INCORRECT - Client teaching should be done by the nurse, because the nurse will need to assess the client's learning and adapt the teaching as needed. 4) CORRECT - An LPN/LVN may titrate O 2 within specified parameters. Therefore, the nurse can delegate this task. 5) INCORRECT - A nurse needs to further assess the client for possible postoperative complications, such as atelectasis or infection. 6) INCORRECT - The nurse needs to assess for a possible ileus.

The nurse reviews nutrition with a client who plans to breastfeed for the next 6 months. Which client statement indicates to the nurse that teaching was successful? 1."I will mix baby cereal in a formula bottle when I am ready to give my baby cereal." 2."My breast milk should be discarded if left in the freezer for 3 months." 3."I should introduce fortified cereal at 2 months of age." 4."My breast milk contains iron that is more easily absorbed than iron-fortified formula."

1) INCORRECT - Cereal should not be mixed into the formula bottle when feeding the healthy newborn. It should be fed by spoon. 2) INCORRECT - Breast milk can be stored in a freezer for 6 months. 3) INCORRECT - Solid foods should be introduced at age 6 months and fed by spoon to the newborn. 4) CORRECT - While the amount of iron in breast milk is less than that in iron fortified formula, it is more easily absorbed by the infant. Neonates born at term have enough iron stores from the mother to last for the first 4 months of life.

The nurse discusses skateboard safety with a group of parents. Which statement is most important for the nurse to include? 1."If your children are younger than 5 years of age, always observe them while they are skateboarding." 2."Carefully check the surface where your child will be skateboarding." 3."It does not matter what type of skateboard you get for your child." 4."Instruct your child to keep as close to the curb as possible."

1) INCORRECT - Children younger than 5 years of age should not skateboard. Developmentally, they have difficulty protecting themselves from injury. 2) CORRECT— The parents should check for holes, bumps, rocks, and debris that may cause an accident. 3) INCORRECT - Skateboards are designed for various uses (slalom, freestyle, or speed). The parents should know how the child plans to use the skateboard. 4) INCORRECT - The child should never ride a skateboard in the street and should not be close to the curb.

The nurse instructs a group of parents about age-appropriate toys for toddlers. Which toys will the nurse recommend that toddlers use? (Select all that apply.) 1.Educational computer programs. 2.Play clothes for dress-up. 3.Pounding board. 4.Cloth picture books. 5.Tricycle. 6.Skates.

1) INCORRECT - Educational computer programs are appropriate for preschoolers, not toddlers. 2) INCORRECT - Play clothes for dress-up are appropriate for preschoolers, not toddlers. 3) CORRECT - A pounding board is an appropriate toy for the toddler, as it promotes physical activity. 4) CORRECT - Cloth picture books are an appropriate toy for toddlers, as they stimulate mental development and creativity. 5) INCORRECT - A tricycle is appropriate for preschoolers, not toddlers. 6) INCORRECT - Skates are appropriate for preschoolers, not toddlers.

The parents sit at the bedside and discuss a bicycle accident involving their older son who was riding his bicycle and accidentally hit their school-age daughter, who experienced a concussion. Which statement made by a parent validates the nursing diagnosis of dysfunctional family process? 1."Our daughter never watches where she's going. She doesn't pay attention." 2."It was an accident. I don't want to hear that our son has always been jealous of her." 3."This would not have happened if you had not stopped at the bar on the way home." 4."We are going to have to talk to our son about bicycle safety."

1) INCORRECT - Never paying attention suggests a possible attention deficit disorder. This is not necessarily a sign of family dysfunction. 2) INCORRECT - Not wanting the client to hear that a brother is jealous suggests possible sibling rivalry. 3) CORRECT- Blaming a spouse for the accident combined with potential substance abuse indicates a dysfunctional family process. Substance abuse is a primary cause of dysfunctional family systems. 4) INCORRECT - Planning to talk to the son about bicycle safety is an appropriate parental response.

The nurse receives report from the previous shift. Which client does the nurse see first? 1.A client with myocardial infarction whose monitoring shows four to six premature ventricular beats per hour. 2.A client with dementia who is confused, agitated, and incontinent of urine and feces. 3.A client with pneumonia who is increasingly confused and has a temperature of 104 °F (40 °C). 4.A client with diabetes who is restless during the night and whose fasting blood glucose is 170 g/dL (9.4 mmol/L). View Explanation

1) INCORRECT - Four to six premature ventricular beats per hour is benign. The nurse is concerned when the client has four to six premature ventricular beats per minute. 2) INCORRECT - The client with dementia who is confused and agitated requires close monitoring but is not urgent. 3) CORRECT- An elevated temperature indicates pneumonia is worse, but by itself is not concerning. Confusion can indicate hypoxia. Fever increases metabolic and oxygen demand, and combined with increasing confusion indicates this client's condition may worsen quickly. 4) INCORRECT - This blood glucose level is not urgently concerning. The nurse will want to assess the cause of the client's restlessness as soon as possible.

The nurse plans care for a client diagnosed with antisocial personality disorder. The client participates in group therapy. Which action is most important for the nurse to take during the group therapy session? 1.Provide time to explore the client's past. 2.Demonstrate acceptance of the client and the client's behavior. 3.Set limits on the client in a nonpunitive manner. 4.Encourage sublimation of the client's leadership potential. View Explanation

1) INCORRECT - Group therapy allows exploration with a therapist to set appropriate limits on the member's behaviors. For the client diagnosed with antisocial personality disorder, the primary goal is to encourage healthy social behaviors. 2) INCORRECT - The nurse should convey acceptance of the client, but not of the inappropriate behaviors. 3) CORRECT— Clients diagnosed with antisocial personality disorders are manipulative and act out. In order to establish trust and avoid power struggles, limits must be set in a nonpunitive manner. 4) INCORRECT - This is not the purpose of group therapy.

The nurse provides care to an older adult client diagnosed with right-sided paralysis caused by a cerebrovascular accident (CVA). Which sign is most important for the nurse to post in the client's room? 1."Keep floor dry and free of debris." 2."Do not use the right arm for lifting." 3."Client is hard of hearing." 4."Client is paralyzed on the right side."

1) INCORRECT - Keeping the floor dry and free of debris is appropriate for every client and not just the client with right-sided paralysis. 2) CORRECT - Because the paralyzed muscles cannot offer resistance, the shoulder can be easily dislocated if the arm is used for lifting. This is a common injury in clients with paralysis, and the sign will help prevent it from occurring. 3) INCORRECT - Posting a sign about a sensory deficit is appropriate, but it is not as significant as the risk for a dislocated shoulder. 4) INCORRECT - Informing about the client's mobility status may help personnel address the client's specific needs, but it does not directly provide specific directions for client management and how to prevent a shoulder injury.

The nurse conducts a quality assurance review of a laboring client's health record. Which entry does the nurse reviewer bring to the attention of the nurse manager? 1.1035: Five minutes after epidural initiated, client's blood pressure is 80/48 mm Hg. Client positioned left side down. 2.1050: Fetal heart rate is 90 to 100 beats/min after epidural block. O 2 by face mask administered to client at 10 L/min. 3.0820: 500 mL IV fluid bolus of Lactated Ringer's solution completed. 1030: Anesthesiologist present to begin administration of epidural block. 4.1102: Fetal heart rate sustained at 100 beats/min for more than 10 minutes. Lactated Ringer's solution infusion rate increased to wide open per protocol. View Explanation

1) INCORRECT - Maternal hypotension causes a decrease in placental perfusion. Positioning the client on the left side is appropriate, as this position increases placental perfusion. 2) INCORRECT - A sustained fetal heart rate of less than 110 beats/min is considered bradycardia. Administration of oxygen to the client is indicated in the event of fetal bradycardia. 3) CORRECT— Epidural blockade produces vasodilation and typically causes a decrease in blood pressure. Administration of an IV fluid bolus prior to an epidural block is intended to offset potential hypotension by increasing the fluid volume in the intravascular space. To optimize the effects of the fluid bolus, the IV fluid should be administered over 20-30 minutes and the epidural procedure begun shortly thereafter. 4) INCORRECT - A sustained fetal heart rate of less than 110 beats/min is considered bradycardia. Administration of IV fluid (without any medication) as prescribed or per protocol is an appropriate intervention for fetal bradycardia.

The home health nurse is planning to visit four clients who live within 3 miles of each other. Which client does the nurse visit first? 1.The newborn who is 20-hours-old, is being breastfed, and has not had a stool since birth. 2.The newborn who has a respiratory rate of 60 breaths/min when crying. 3.The client who is at 30 weeks' gestation, has gestational diabetes mellitus (GDM), and has a blood sugar of 78 mg/dL (4.3 mmol/L). 4.The client who is at 34 weeks' gestation with twins and is reporting intermittent low back pain.

1) INCORRECT - Meconium, the first stool of the newborn, may be passed anytime within 12 to 24 hours. 2) INCORRECT - The normal respiratory rate for newborns is 30 to 60 breaths/min. Placing a hand lightly over the abdomen or watching the abdomen rise and fall also helps to identify each breath. If the newborn is crying, a pacifier or gloved finger to suck may quiet the neonate so the respiratory rate can be counted accurately. The nurse should expect the respiratory rate to be higher when the newborn is crying. 3) INCORRECT - Hypoglycemia occurs when the blood sugar is below normal (<70 mg/dL [<3.9 mmol/L]). 4) CORRECT- Many twins or higher multiples are born prematurely because the uterus becomes overly distended. Intermittent low back pain is a sign of labor. This client should be assessed first.

The nurse oversees care provided by an LPN/LVN and an unlicensed assistive personnel (UAP). Which task is best to delegate to the UAP? 1.Monitor a client during the first 15 minutes after the nurse begins a blood transfusion. 2.Determine the patency of a chest tube drainage system for a client diagnosed with a pneumothorax .3.Teach a client newly diagnosed with type 1 diabetes mellitus how to fill out the menu. 4.Implement bladder training measures for a client diagnosed with urinary incontinence.

1) INCORRECT - Monitoring a client receiving a blood transfusion is the responsibility of the nurse. 2) INCORRECT - Determining the patency of a chest tube drainage system is the responsibility of the nurse. The UAP can measure and record chest tube drainage. 3) INCORRECT - Client teaching is the responsibility of the nurse. 4) CORRECT- The UAP can be delegated activities related to bladder training. Establishing the bladder training program is the responsibility of the nurse.

A client follows a lacto-vegetarian eating plan. Which recommendation is appropriate for the nurse to suggest to this client? 1.Limit the intake of eggs to three per week. 2.Increase consumption of breads and pastas. 3.Increase intake of beans, legumes, and nuts. 4.Supplement diet with calcium and magnesium tablets.

1) INCORRECT - People who follow a lacto-vegetarian eating plan consume milk and dairy products but do not eat eggs. 2) INCORRECT - Increasing the consumption of bread and pasta will not increase amino acids and protein stores to support the client's health needs. 3) CORRECT— The client should increase the intake of protein from other sources, such as seeds, tofu, and dark green vegetables, along with beans, legumes, and nuts. 4) INCORRECT - Since the client consumes dairy products, calcium and magnesium consumption should not be a problem.

The nurse teaches a group of pregnant clients about prenatal care. Which client statement requires follow up by the nurse? 1."I will avoid changing my cat's litter box." 2."I will drink 8 glasses of water a day." 3."I will put my legs up on a pillow when I lie on my back to watch television." 4."I can continue with my exercise class until I become too short of breath." View Explanation

1) INCORRECT - Pregnant clients should avoid materials contaminated with cat feces, such as litter boxes, sand boxes, and garden soil, to prevent toxoplasmosis. This does not require follow up by the nurse. 2) INCORRECT - Pregnant clients should drink 8 to 10 8-oz glasses of fluid each day, most of which should be water. This does not require follow up by the nurse. 3) CORRECT- Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. The heavy uterus compresses her inferior vena cava, reducing the amount of blood returned to her heart. Circulation to the placenta may also be reduced by increased pressure on the woman's aorta, resulting in fetal hypoxia. The nurse should instruct the client to lie on her side. 4) INCORRECT - Unless otherwise contraindicated, women can continue to exercise during pregnancy as tolerated.

The outpatient clinic nurse administers a tuberculin skin test (TST) to four adult clients. The nurse anticipates which client will likely demonstrate a false-positive response to the TST? 1.A client who received a herpes zoster (shingles) vaccine last week. 2.A client who received a bacille Calmette-Guerin (BCG) vaccine 1 month ago. 3.A client who regularly takes corticosteroid medication. 4.A client who was recently diagnosed with AIDS.

1) INCORRECT - Recent administration of a live virus vaccine (including for prevention of herpes zoster [shingles], measles, and mumps) may cause a false-negative, not false-positive, response to a TST. The Centers for Disease Control and Prevention (CDC) recommends either administering the live virus vaccine on the same day as the TST or waiting 4-6 weeks after administration of the live virus vaccine to perform the TST. 2) CORRECT— Clients who receive a BCG vaccine, which prevents against the development of tuberculosis (TB), may demonstrate a false-positive response to a TST. 3) INCORRECT - Corticosteroid medications suppress the immune response. Clients who take corticosteroid medications are likely to demonstrate a false-negative, not false-positive, response to a TST. 4) INCORRECT - AIDS is characterized by profound suppression of the immune system. Clients diagnosed with AIDS are likely to demonstrate a false-negative, not a false-positive, response to a TST.

The nurse provides care to a prenatal client who is 2 months pregnant. The client reports experiencing nausea each morning. Which recommendation does the nurse provide to the client? 1.Consume only soft foods and fruit until evening. 2.Eat pretzels before getting out of bed in the morning. 3.Avoiding drinking carbonated beverages. 4.Limit food intake to three full meals each day.

1) INCORRECT - Soft foods and fruit are not necessarily effective in alleviating pregnancy-related nausea. In addition, limiting dietary intake to only soft foods and fruit may not meet the nutritional requirements for a healthy pregnancy. 2) CORRECT - Strategies to prevent or decrease pregnancy-related nausea include eating dry carbohydrate foods (such as pretzels) 30 minutes to 1 hour prior to getting out of bed in the morning. 3) INCORRECT - Rather than avoiding carbonated beverages, the client should be advised to drink a carbonated beverage when nausea occurs. Consumption of carbonated beverages is a recommended strategy for relieving nausea during pregnancy. 4) INCORRECT - To help alleviate pregnancy-related nausea, the client should be advised to consume several small meals throughout the day, not three full meals.

The nurse provides care for a client diagnosed with tuberculosis. Which transmission-based precautions will the nurse implement? 1.Standard. 2.Airborne. 3.Droplet. 4.Contact.

1) INCORRECT - Standard precautions are used when caring for all clients, regardless of diagnosis or possible infection. 2) CORRECT— Tuberculosis is transmitted by airborne droplets. The nurse implements airborne precautions. 3) INCORRECT - Tuberculosis is transmitted by airborne droplets. The nurse implements airborne precautions, not droplet precautions. 4) INCORRECT - Tuberculosis is transmitted by airborne droplets. The nurse implements airborne precautions, not contact precautions.

The nursing team on a medical-surgical floor consists of two nurses: one unlicensed assistive personnel (UAP) and one nurse reassigned from the postpartum unit. Which client will the charge nurse assign to the postpartum unit nurse? 1.A client diagnosed with spinal cord injury and who requires assistance with meals. 2.A client diagnosed with a myocardial infarction and who reports burning on urination. 3.A client diagnosed with terminal cancer and who exhibits Cheyne-Stokes respirations. 4.A client diagnosed with a head injury with a Glasgow Coma Score of 7.

1) INCORRECT - The client requires assistance with a standard, unchanging procedure. This may be assigned to the UAP. 2) CORRECT - The reassigned nurse is given the same type of clients as an LPN/LVN. The reassigned nurse should be assigned stable clients with expected outcomes. 3) INCORRECT - Cheyne-Stokes respirations are periodic breathing characterized by rhythmic waxing and waning of the depth of respirations. Cheyne-Stokes respirations are indicative that the client may be dying imminently. This client requires experienced assessment and should not be delegated to the reassigned nurse. 4) INCORRECT - A Glasgow Coma Score of 8 or less indicates severe brain damage. This client requires experienced assessment and should not be delegated to the reassigned nurse.

The nurse on the psychiatric unit is providing care for a client who takes fluvoxamine at bedtime. Morning laboratory results reveal Na+ 124 mEq (124 mmol/L) and serum osmolality 270 mOsm/kg (270 mmol/kg). Which action does the nurse take first? 1.Place the client on one-to-one suicide precautions. 2.Prepare to administer NaCl 0.9% intravenously. 3.Initiate seizure precautions with constant observation. 4.Assess for adverse effects experienced during the night.

1) INCORRECT - The nurse must assess for suicidal ideation before implementing precautions. There is no evidence that client is at risk for self-harm. 2) INCORRECT - Hypertonic fluids are typically administered for a client with hyponatremia. However, beginning IV fluids is not the priority. The client has hypo-osmolar imbalance (270 mOsm/kg (270 mmol/kg) and is hyponatremic (Na+ 124 mEq), so hypotonic fluids (0.45% NS) will worsen the client's medical condition, and isotonic fluids (normal saline, NaCl 0.9%), NS) may not be helpful. 3) CORRECT - The client is at high risk for convulsions and cerebral edema and needs monitoring to prevent further water intake. The lab results suggest dilutional hyponatremia, possibly from obsessive-compulsive water intake (i.e., psychogenic polydipsia), excessive drinking to stop medication side effect of thirst, or as a direct adverse effect of the medication. 4) INCORRECT - It is good to get more information from the client regarding symptoms that correspond with this labwork, but safety is the priority.

The nurse receives change of shift report. Which client does the nurse assess first? 1.A client who had a partial lobectomy and has a chest tube. 2.A client who had a total laryngectomy 12 hours ago. 3.A client complaining of a headache for the past hour. 4.A client in Buck 's traction for a fracture of the right femur.

1) INCORRECT - The post-lobectomy client should be stable. This client is assessed second due to the critical nature of the surgery and chest tube, which can impact the ability to maintain an effective respiratory pattern. 2) CORRECT- The post-laryngectomy client will be learning to communicate using alternate methods. This client is at risk of airway loss related to excess mucus production, bleeding, and/or edema from surgical trauma. 3) INCORRECT - The client with a headache is likely stable in the absence of other symptoms. 4) INCORRECT - The client in traction without any other symptoms should be stable. This client is at risk for neurovascular alterations and pulmonary obstruction due to fat embolism.

The nurse instructs a client about how to use an incentive spirometer. Which instruction does the nurse include? 1."Hold the spirometer at a 45-degree angle while breathing in. " 2."Exhale into the spirometer for 3 seconds. " 3."Inhale through the mouthpiece and hold your breath for 3 seconds. " 4."Hold the spirometer straight to allow the aerosol to enter lungs. "

1) INCORRECT - The spirometer is held upright at eye level so a client can observe the ball rise in the chamber. The purpose is to promote complete lung expansion and to prevent respiratory complications in the postoperative client. 2) INCORRECT - The correct method is to inhale deeply and to hold the breath for 3 seconds. 3) CORRECT— Inhaling deeply and holding for 3 seconds allows for a sustained maximal inspiration to prevent atelectasis. A client is able to see their efforts registered on the spirometer. 4) INCORRECT - Aerosol is not used in a spirometer, although the spirometer is held upright.

The nurse in the pediatric clinic performs a physical assessment on an adolescent male client. Which finding by the nurse requires an immediate intervention? 1.The client reports his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes. 2.The nurse notes that the client has unilateral breast enlargement. 3.The client's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass. 4.The client's scrotum appears enlarged and red. The nurse palpates a thickened and swollen spermatic cord.

1) INCORRECT - These findings represent a varicocele, which is a scrotal mass due to enlarged veins of the spermatic cord. The client may require a scrotal support if uncomfortable. Varicoceles are a major cause of male infertility, but this is not an emergency situation. 2) INCORRECT - This finding represents gynecomastia. Transient gynecomastia occurs in approximately half of adolescent boys and may be either unilateral or bilateral. It usually lasts about 1 year before resolution. 3) INCORRECT - These findings represent an inguinal hernia, which is the protrusion of a loop of bowel into the scrotum. While the nurse should refer the client to a health care provider for further evaluation, this is not an emergency situation. 4) CORRECT - These findings represent torsion of the spermatic cord. This is very painful and is an emergency situation, which requires immediate surgical repair. Testicular torsion is the most common cause of testicular loss in young males due to hypoxic injury to the testicle.

The nursing team consists of a nurse, an LPN/LVN, and two unlicensed assistive personnel (UAPs). Which client does the nurse assign to the LPN/LVN? 1.A client 2 days postoperative after abdominal hysterectomy asks to ambulate in the hall. 2.A client with a colostomy requires assistance with an irrigation. 3.A client diagnosed with a right-sided stroke requires assistance with bathing. 4.A client refuses medication for treatment of cancer of the colon.

1) INCORRECT - This can be assigned to an UAP. The nurse will give clear directions as to how far to ambulate the client and any untoward effects that should be reported to the nurse. 2) CORRECT - This is a stable client with an expected outcome and who needs a task performed that is within the scope of practice of the LPN/LVN. 3) INCORRECT - This is a standard, unchanging procedure and may be assigned to the UAP. 4) INCORRECT - This client requires evaluation and teaching. The nurse will remain with this client.

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first? 1.A 3-year old with a fever, an earache, and vomiting since yesterday. 2.A 5-year old reporting leg and arm pain after falling from a treehouse. 3.A 21-year old at 8 weeks' gestation reporting unilateral abdominal pain. 4.A 40-year old who reports nausea, general anxiety, and is diaphoretic.

1) INCORRECT - This client likely has an ear infection and the nurse monitors the client until the client can be evaluated by a HCP. 2) INCORRECT - Assess the neurovascular status of the affected extremities, then ice, splint, and elevate it until evaluation by the HCP. 3) INCORRECT - Ask the client to rest and offer reassurance until evaluated by HCP. This may be an ectopic pregnancy. This client needs continuous monitoring, frequent comforting, and to be evaluated as quickly as possible. The loss of a pregnancy in this manner cannot be stopped. The goal is to prevent rupture and internal hemorrhage. 4) CORRECT - Even though not complaining of chest pain, these symptoms should be treated as a potential MI. A cardiac workup should be performed immediately.

During a conversation with the nurse, a client on the psychiatric unit says, "When you are in the hospital, everyone wants you to talk about your problems, but it is not that way on the outside. Nobody wants to hear about your problems there. They just walk away." Which response by the nurse is best? 1."Applying communication techniques you have learned here will help you to get people to respond differently." 2."People do often seem wrapped up in their own lives, don't they?" 3."Do not worry. I am sure you will find people who will listen." 4."It will be important to be connected with support people and groups, especially in the beginning."

1) INCORRECT - While it is true that the techniques may improve the client's communication overall, they do not guarantee an adequate support system. 2) INCORRECT - This does not address the client's concerns, but instead reinforces them. It does not focus on the client's concerns 3) INCORRECT - "Do not worry" is nontherapeutic. It blocks discussion and negates the client's concerns. 4) CORRECT - This acknowledges the reality of the client statement and offers alternatives, stressing their importance and the legitimacy of using them.

Which finding during a newborn client examination requires immediate action by the nurse? 1.The left side of the newborn's face is drooping. 2.The newborn's uvula has two lobes. 3.The newborn's ears are low-set bilaterally. 4.The red reflex is absent in the newborn's right eye.

1) INCORRECT — Facial drooping may indicate facial paralysis from damage to cranial nerve VII (facial nerve), which occurred during delivery. This paralysis usually resolves within a few days to 3 weeks, though it can be permanent. This is a self-resolving matter. The nurse needs to teach the parents about care and feeding. 2) INCORRECT — A bifurcated uvula indicates there may be a cleft in the palate. Further assessment of sucking ability and/or hard and soft palate size, shape, and cleft formations should be made, but this is not urgent. 3) INCORRECT — Low set ears are an indication that Down syndrome may be present. Further assessment findings to confirm this include flat occiput, broad nasal bridges, eyes that have epicanthal folds and slant upward, large tongue, high palate, and small chin. The nurse needs to begin teaching the parents about this child's needs. 4) CORRECT — The absence of a red reflex indicates an ophthalmic emergency. This is because light is not being transmitted to the retina, and the early suppression of optic nerve function, which results in the obstruction of the light, can cause blindness. Notify the health care provider immediately.

The nurse assesses a client who received a blunt head injury from a motorcycle crash. Which finding indicates a basal skull fracture? 1.Periorbital edema. 2.Epistaxis. 3.Purulent drainage from the auditory canal. 4.Bloody or clear drainage from the auditory canal.

1) INCORRECT — Periorbital edema is not specific to a basal skull fracture. 2) INCORRECT — A nosebleed is not specific to a basal skull fracture. 3) INCORRECT — Purulent drainage from the auditory canal is not specific to a basal skull fracture. It may indicate an ear infection. 4) CORRECT — Bloody or clear drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture.

A Buddhist client dies on the medical unit in a private room from terminal cancer. Family and friends have gathered around the bedside. Which action by the nurse is best? 1.Provide a basin of warm water and a washcloth. 2.Hand the closest family members a clean white sheet. 3.Close the door to provide privacy for chanting around the bedside. 4.Call the hospital chaplain to tie a thread around the neck or waist.

1) INCORRECT — This would be appropriate if the client were Hindu. In Hinduism, a priest pours water into the mouth of the deceased and the family washes the body before cremation. 2) INCORRECT — There is no particular need for this. 3) CORRECT — In Buddhism, those at the bedside after the death often perform last rites of chanting. A Buddhist priest should be contacted by the nurse or family. 4) INCORRECT — This is not appropriate for a Buddhist client. In Hinduism, a Hindu priest may be called when death has occurred and, as a blessing, might tie a string around the waist or neck of the deceased.

The charge nurse makes rounds on the psychogeriatric unit. Which situation requires immediate intervention by the charge nurse? 1.The dietary aide removes a full breakfast tray untouched by a client with major depression who is still in bed wearing night clothing. 2.The unlicensed assistive personnel (UAP) makes the bed while a client with schizophrenia is sitting in the bedside chair shaving with a disposable razor and mirror. 3.The LPN/LVN assigned to medication administration argues loudly with a client with bipolar disorder who is refusing to take prescribed medication. 4.The UAP places personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water.

1) INCORRECT- These are expected signs of depression that need to be addressed, but they are not the priority. The client has a decreased appetite and will likely not eat even if the dietary aide leaves the tray. 2) INCORRECT- Self-care with sharp items is allowed under staff supervision, and this client is supervised. 3) INCORRECT- The LPN/LVN 's behavior needs addressing. The client may have the right to refuse medication. However, addressing the choking risk for the client with dementia is the priority. 4) CORRECT- The client with Alzheimer disease is at risk for choking on inedible items such as soap, lotions, and caps of sample bottles.

The nurse provides care for a pediatric client who is 18 months of age during a wellness visit. The nurse assesses the child's growth and development. Which assessment finding causes the nurse to be concerned? 1.The child does not follow basic instructions. 2.The child does not use two-word sentences. 3.The child has difficulty with stairs. 4.The child does not speak 15 words.

1) INCORRECT— Inability to follow basic commands by age 2 years (not 18 months) is a cause for concern. 2) INCORRECT— Not using two-word sentences is a cause for concern for a child age 2 years, not 18 months. 3) INCORRECT— Difficulty with stairs at age 3 years (not 18 months) is a cause for concern. 4) CORRECT— A cause for concern for a child age 18 months is an inability to speak 15 words.

A nurse prepares to perform blood pressure screenings at a health fair in the local community center. Which part of the preparation receives the most attention? 1.Ensure that there will be several quiet rooms near the main gathering area. 2.Collect blood pressure cuffs of varied sizes. 3.Arrange low-cholesterol snacks for participants. 4.Procure booklets that explain hypertension in simple language.

1) INCORRECT— This may be useful to enhance the examiner's ability to hear the Korotkoff sounds and also to engage in discussion with participants. However, there is another answer that is a higher priority. 2) CORRECT — Having blood pressure cuffs of varied sizes is essential to ensure accurate blood pressure readings. People attending the fair almost certainly will vary in arm size. A cuff that is too small will produce a falsely high reading, while a cuff that is too large will produce a falsely low reading. The nurse will ensure the ability to obtain accurate readings. 3) INCORRECT— This may help attract people to have their blood pressure taken, but another action is a higher priority. 4) INCORRECT— Having written materials for later review is appreciated by many people, but another action is a higher priority.