7.9.19 C

The unlicensed assistive personnel (UAP) reports to the nurse that four clients are vomiting. Which client does the nurse see first? 1. A client with a nasogastric (NG) tube attached to low suction. 2. A client diagnosed with cirrhosis of the liver who has extensive ascites. 3. A client diagnosed with lung cancer who is undergoing chemotherapy. 4. An older adult client diagnosed with irritable bowel syndrome (IBS).

1

The nurse provides care for a client who is scheduled to receive spinal anesthesia. It is most important for the nurse to take which action when providing care to this client? 1. Ensure that the client is adequately hydrated before the procedure. 2. Assess for allergies to iodine. 3. Ensure that the client does not eat for 12 hours before the procedure. 4. Determine the specific gravity of the client's urine.

1 3) INCORRECT - This is theoretically not necessary for spinal anesthesia, as the client will not be unconscious and the gag reflex will not be inhibited. However, situations can arise that require general anesthesia or sedation. Therefore, clients may be NPO prior to spinal anesthesia, but this is not the most important nursing action specifically related to the anesthesia.

The nurse teaches a client who is prescribed prednisone for systemic lupus erythematosus (SLE). Which information related to prednisone does the nurse include in the teaching plan? (Select all that apply.) 1. Report any symptoms of infection. 2. Do not discontinue medication abruptly. 3. Take medication at bedtime. 4. Report unusual weight gain. 5. Get vaccinated for influenza. 6. Avoid salt substitutes.

1.2.4

The nurse provides teaching to the parents of a newborn. Which parent statement requires an intervention by the nurse? (Select all that apply.) 1. "Since our baby seems to prefer formula to breast milk, I will stop breastfeeding." 2. "We will feed our baby formula until my breast milk comes in." 3. "If our baby continues to suck after the feeding, we can use a pacifier to soothe our baby." 4. "We will not give our baby a pacifier, due to an increased risk of sudden infant death syndrome (SIDS)." 5. "I will call the health care provider's office if my baby does not have at least six wet diapers per day." 6. "I will not worry if our baby's bowel movements are sticky and black at first."

1.2.4 Explanation Step-By-Step Walkthrough 1) CORRECT — The nurse should recommend that the parents not offer formula if breastfeeding. The newborn may become confused and refuse breast milk. 2) CORRECT — Parents planning to breastfeed should not offer formula. The newborn will obtain nutrient-rich colostrum before the breast milk comes in. 3) INCORRECT — This is a correct statement, and the parents need no further teaching. 4) CORRECT — Pacifier use is associated with a reduced risk of SIDS, not an increased risk. 5) INCORRECT — This is a correct statement, and the parents need no further teaching. 6) INCORRECT — This is a correct statement describing meconium stools

The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.) 1. Sing or talk to the client throughout the activity. 2. Expose only one area at a time while bathing. 3. Complete the bath as quickly as possible. 4. Organize all supplies before starting the bath. 5. Bathe the client slowly and explain each action.

1.2.4.5

The nurse teaches a class to pregnant clients. The nurse discusses fetal movements and positions during labor that facilitate the birth of the fetus. Which information does the nurse include? (Select all that apply.) 1. The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. 2. The most common orientation is the transverse lie. 3. The fetal attitude is normally one of flexion. 4. The fetal head is fully flexed in the brow presentation. 5. The fetal occiput is in the left front quadrant of the mother 's pelvis.

1.3.5

The nurse reviews laboratory values for a group of clients. Which results does the nurse report to the health care provider? (Select all that apply.) 1. Positive nitrates in the urinalysis of a client receiving chemotherapy. 2. An activated partial thromboplastin (aPTT) level of 78 seconds in a client receiving an IV heparin infusion. 3. A blood urea nitrogen (BUN) level of 68 mg/dL (24.3 mmol/L) in a client diagnosed with kidney failure receiving hemodialysis. 4. A blood glucose level of 140 mg/dL (7.77 mmol/L) in a client diagnosed with diabetes mellitus receiving IV methylprednisolone. 5. A serum potassium level of 3.3 mEq/dL (3.3 mmol/L) in a client receiving IV antibiotics.

1.4.5 1) CORRECT - The presence of nitrates indicates an infection caused by E. coli. Since the client is receiving chemotherapy, the client is at risk for myelosuppression. 2) INCORRECT - The aPTT is normally 25 to 39 seconds. Since the client is receiving an infusion of heparin, the level of 78 seconds is within the therapeutic range. 3) INCORRECT - A BUN level of 68 mg/dL (24.3 mmol/L) is abnormal, but is expected for a client diagnosed with end-stage kidney disease. 4) CORRECT - Corticosteroids may cause hyperglycemia. Special care should be used in treating clients diagnosed with diabetes mellitus. 5) CORRECT - Antibiotics can destroy the normal flora of the gastrointestinal tract leading to diarrhea and the excretion of potassium. The level of 3.3 mEq/dL (3.3 mmol/L) is below normal and indicates a potassium loss.

The nurse provides care for a client diagnosed with full-thickness burns. In planning the debridement of the burn, the nurse gives priority to which action? 1. Assemble all necessary supplies and medications. 2. Plan a time to perform the dressing change. 3. Prepare the client mentally for the procedural pain. 4. Limit visitors before, during, and after the procedure.

2

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.

2

While working at a local food processing plant, a flying object penetrates an employee's right eye. The employee is admitted to an emergency department. After administering pain medication, which question is most important for the nurse to ask? 1. "Does the company provide worker's compensation?" 2. "Do you wear glasses?" 3. "Did you have visual problems before the injury?" 4. "Are you afraid?"

2

The nurse prepares to complete a health history with a client seeking treatment at the medical clinic for diabetes mellitus. Which question will best provide information about the client's reason for seeking medical care? 1. "Has your diabetes been under control?" 2. "Tell me why you came to the clinic today." 3. "How has your health been lately?" 4. "Describe to me how you are feeling".

2 tells the most about why the client came in

The spouse of a client diagnosed with multiple myeloma asks the hospice nurse for pain control suggestions since the prescribed medication makes the client sleepy. Which responses by the nurse are appropriate? (Select all that apply.) 1. "It is all right for your spouse to sleep all the time. We don't want your spouse to be in pain." 2. "Let me show you some techniques of massage, which may help relieve the pain." 3. "Please locate some of your spouse's favorite music and see if listening to it helps with relaxation." 4. "I will contact the health care provider about changing the pain medication." 5. "Since pain control is getting to be a problem, it is time to consider placing your spouse in an inpatient setting." 6. "I can see you are worried about your spouse. You may want to ask your health care provider for medication to help you cope with this difficult situation."

2.3 2) CORRECT — Massage can help reduce both acute and chronic pain. The nurse is actively showing the spouse how to help the client. 3) CORRECT — Music is used as a cognitive therapy for relaxation and a distraction from pain.

The nurse educates a client about family planning and contraceptive methods. Which information does the nurse include in the teaching session? (Select all that apply.) 1. Breastfeeding is as effective as oral contraceptives for preventing pregnancy. 2. Barrier contraceptive devices can prevent sexually transmitted infections (STIs). 3. Some medications can decrease the effectiveness of oral contraceptives. 4. A vasectomy is an easily reversed method of male contraception. 5. Using a diaphragm increases the risk for urinary tract infection (UTI).

2.3.5

The nurse assesses several newborns after delivery. Which findings are anticipated by the nurse during the physical examination? (Select all that apply.) 1. Respiratory grunting. 2. Head circumference 13 in (33 cm). 3. Respiratory gasping. 4. Irregular respiration. 5. Chest circumference 10 in (25 cm).

2.4 1) INCORRECT - Grunting is an abnormal finding. It indicates respiratory distress. 2) CORRECT—Normal head circumference is 13 to 14 in (33 to 35 cm). 3) INCORRECT - Gasping is an abnormal finding. It indicates respiratory depression. 4) CORRECT—Irregular respiration is a normal finding. However, a period of apnea > 20 seconds or with a change in heart rate or color is abnormal and indicative of respiratory depression, sepsis, and/or cold stress. 5) INCORRECT - This is an abnormal finding. Normal chest circumference is 12 to 13 in (30.5 to 33 cm).

The nurse assesses a client diagnosed with a descending colon tumor. Which characteristic symptoms of this type of tumor does the nurse ask the client about during the physical examination? (Select all that apply.) 1. Early satiety. 2. Rectal bleeding. 3. Colicky abdominal pain. 4. Flat, ribbonlike stools. 5. Alternating diarrhea and constipation.

2.4.5

The nurse instructs a group of high school parents at a local health fair. Which statements by the parents during the discussion period require follow up by the nurse? (Select all that apply.) 1. "My teenager is very independent and doesn't need constant supervision after school." 2. "My teenager can be impulsive at times, but is improving on problem solving skills." 3. "Although I've made some mistakes in my life, I feel that I am a good role model for my teenager." 4. "My child is moody and requires some guidance when frustrated with homework." 5. "It is important to consistently tell my teenager what to do every day."

2.5

A child diagnosed with status asthmaticus, receiving oxygen 50% per an air-entrainment mask, has a pulse of 120 beats/min, respirations 26 breaths/min, and a temperature of 98.6°F (37.0°C). Which observation causes the nurse the most concern? 1. Expiratory wheezing. 2. Dusky fingertips. 3. Oxygen saturation is 85%. 4. Intercostal retractions.

3

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? 1. Wrinkling. 2. Deepening of expression lines. 3. Crusting. 4. Thinning and loss of elasticity.

3

The nurse provides care for an infant immediately after a surgical procedure. Which nursing action is the most important? 1. Minimize stimuli for the infant. 2. Restrain all extremities. 3. Encourage the parents to stroke the infant. 4. Explain to the parent how to assist with the infant's care.

3 3) CORRECT— Tactile stimulation is imperative for an infant's emotional development and provides essential comfort.

The parish nurse knows that it is most important to encourage which parishioner to obtain screening for prostate cancer? 1. A Caucasian young adult computer programmer diagnosed with cryptorchidism. 2. An Asian-American adult restaurant owner diagnosed with ulcerative colitis. 3. An African-American middle-aged adult factory worker in automobile tire manufacturing. 4. A Caucasian older adult retired house painter who has been smoking for 40 years.

3. 3) CORRECT — This client has three major risk factors for prostate cancer: age, race, and employment. Prostate cancer is found most commonly in men age 50 and over. African Americans are affected more than other ethnic groups. Occupation and environment are other definite risk factors, particularly exposure to carcinogens found in urban areas (which have a higher incidence of prostate cancer) and in occupations such as fertilizer, rubber, and textile industries. 4) INCORRECT— This client has one risk factor for prostate cancer, his age. His smoking status and exposure to paint are risk factors for lung or bladder cancer.

The nurse is making client assignments on a medical-surgical unit. The staff includes one nurse, an LPN/LVN, and an unlicensed assistive personnel (UAP). Which client does the nurse assign to the LPN/LVN? 1. A client who had a detached retina surgically repaired 4 hours ago. 2. A client who requires toileting assistance after receiving bowel prep for abdominal surgery. 3. A client who is 1 day postoperative after an appendectomy. 4. A client who is 1 day postoperative after a laminectomy with spinal fusion.

3. 4) INCORRECT - This client requires neurological assessment and teaching. The nurse is the appropriate caregiver.

The nurse provides care for an older adult client who requires bilateral eye patches. Which action is appropriate for the nurse to take with this client? 1. Sedate the client until the eye patches are removed. 2. Place the client in a private room. 3. Maintain a calm, dark environment. 4. Frequently touch the client while speaking.

4

The nurse provides care for clients on the medical and surgical unit. Which observation requires intervention by the nurse? 1. The health care provider prepares to insert the needle for a lumbar puncture at the level of the posterior iliac crest. 2. As the nurse leaves the client 's room, the nurse removes gloves and then the gown, folding the gown inside out. 3. The unlicensed assistive personnel (UAP) feeds a client while the client 's neck and head are flexed slightly forward. 4. The LPN/LVN repositions a client in Buck traction by first removing the traction weights.

4

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour? 1. A postpartum client who delivered 4 hours ago and has an intact perineum. 2. A postpartum client diagnosed with an infection who has been receiving antibiotics for the past 24 hours. 3. A toddler with newly diagnosed type 1 diabetes mellitus, diarrhea, and vomiting. 4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L).

4 1) INCORRECT - This is the second most stable client. The client still has a potential risk of bleeding postpartum. 2) INCORRECT - There is not enough information to judge the status of the client with the infection, or whether the antibiotics are effective. 3) INCORRECT - This is the most unstable client. This client requires frequent assessment of hydration status and blood glucose levels. 4) CORRECT- This is the most stable client. Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L). Therefore, the current serum bilirubin level does not indicate the need for treatment.

The nurse provides care for a client who needs fluorescein angiography. Which client statement indicates to the nurse that further teaching is required? 1. "I'll have to wear dark glasses for a while." 2. "I may notice yellow staining of my skin, but it will disappear." 3. "I will have to drink more fluids immediately after the test." 4. "The test determines the amount of pressure within my eyes."

4 1) INCORRECT — Fluorescein is a dye administered IV, and fluorescein angiography is a series of photographs that detail the eye's circulation. The eyes are dilated with mydriatic eye drops before the exam. After the exam, the client should avoid direct sunlight until the eyes have returned to normal. 2) INCORRECT — Fluorescein is administered IV, and the dye does cause temporary staining of the skin. 3) INCORRECT — Drinking lots of fluids helps eliminate the dye. 4) CORRECT— Tonometry measures pressure in the eye. Fluorescein angiography measures circulation in the retina.

The nurse instructs a client diagnosed with cholecystitis. The nurse determines that teaching is effective when the client selects which meal? 1. Liver with onions, cucumber salad, skim milk. 2. Scrambled eggs, bagel with cream cheese, apple juice. 3. Guacamole with chips, bean burrito, herbal iced tea. 4. Barbecued chicken, green peas, lemonade.

4 1) INCORRECT- Liver is high in fat, and onions and cucumber promote gas production. 2) INCORRECT- Eggs and cream cheese are both high in fat. 3) INCORRECT- Guacamole has avocado, which is high in fat. The chips are likely to be fried and high in fat, and beans are high in gas-producing substances. 4) CORRECT- The client diagnosed with cholecystitis should consume a low-fat, low-carbohydrate, and high-protein diet. Barbecued chicken, green peas, and lemonade are all low-fat, low-carbohydrate, and high-protein foods.

The nurse provides care for clients at the local eye care center. Several clients who are 24 hours post-operative after intracapsular cataract extraction have left phone messages. Which message should the nurse return first? 1. A client asks if it is appropriate to take acetaminophen for discomfort in the operative eye. 2. A client reports feeling light-headed when assuming a standing position. 3. A client reports mild itching in the operative eye. 4. A client states that the eyelid is swollen and the client is having difficulty seeing with the affected eye.

4 4) CORRECT— A complaint of a swollen eyelid and difficulty seeing may indicate a bacterial infection. This phone message is priority and needs to be returned first.

The nurse notes that a client receiving parenteral nutrition (PN) suddenly is dyspneic, diaphoretic, anxious, restless, coughing, and reporting chest pain. Which action does the nurse take first? 1. Take the client 's vital signs and auscultate heart and lung sounds. 2. Call for the crash cart and notify the health care provider. 3. Slow down the PN solution and administer insulin as prescribed. 4. Turn the client on the left side and lower the head of the bed.

4 4) CORRECT- These symptoms indicate an air embolism, a central line -related complication that can occur from catheter insertion, tubing changes, or catheter breaking. The left lateral Trendelenburg position is essential to move air away from the pulmonary artery and into the apex of the heart. After changing the client's position, the nurse will obtain assistance and notify the HCP.

The nurse provides care for a pediatric client diagnosed with early stage chronic kidney disease (CKD). Which assessment finding does the nurse expect? 1. Anuria. 2. Oliguria. 3. Polydipsia. 4. Polyuria.

4- kidneys not able to concentrate urine in the begining = lotta pee CKD general (not specific to early dx)- weight gain, electrolyte disturbances (e.g. hyperkalemia, hypocalcemia, hypomagnesemia, and hyperphosphatemia), edema, oliguria or anuria, anemia, malaise, pruritus, muscle cramping, anorexia, confusion, asterixis, and metabolic acidosis

During the initial period following a spinal cord injury, which action is most important for the nurse to take? 1. Prevent contractures and atrophy. 2. Prevent urinary tract infections. 3. Promote rehabilitation. 4. Prevent flexion or hyperextension of the spine.

4.

The nurse provides care for a client who began receiving epoetin alfa injections 10 days ago. It is most important for the nurse to report which information to the health care provider? 1. The client reports walking around the block. 2. The client's blood pressure is 130/80 mm Hg. 3. The client reports flu-like symptoms. 4. The client's hematocrit increases from 28% (0.28) to 34% (0.34).

4. A jump of more then 4 points in two weeks in hematocrit increases risk of siezures and HTN