CAT 3

The nurse makes assignments for the health care team that includes two licensed practical nurses/licensed vocational nurses (LPNs/LVNs) and a nursing assistive personnel (NAP). Which client is most appropriate to assign to the LPN/LVN? (Select all that apply.) 1.Client reporting substernal chest pain.2.Client with a chest tube who is ambulating in the hall.3.Client with a colostomy who requires assistance with colostomy irrigation.4.Client who is refusing medication to treat colon cancer.5.Client diagnosed with heart failure who requires assistance bathing.

1) A client with chest pain requires an assessment of the nurse. 2) CORRECT — This is stable client and a LPN/LVN can appropriately provide care. 3) CORRECT — This is a stable client and a LPN/LVN can appropriately provide care. 4) This client requires assessment of the nurse and appropriate follow up if the refusal continues. 5) The NAP can assist with bathing of the client even though this client requires observation and assessment by the nurse.

The nurse assesses a client recovering from an acute myocardial infarction (MI). Which assessment finding indicates to the nurse that the client is developing cardiogenic shock? 1.Temperature 97.4ºF (36.3ºC). 2.Heart rate 58 beats/min. 3.Respiratory rate 10 breaths/min. 4.Blood pressure 100/88 mm Hg.

1) A lower than normal temperature is associated with neurogenic, not cardiogenic, shock. 2) Bradycardia is associated with neurogenic, not cardiogenic, shock. 3) Bradypnea is a late finding in obstructive, not cardiogenic, shock. 4) CORRECT — Hypotension with a narrow pulse pressure is a clinical manifestation associated with cardiogenic shock.

The nurse assesses the respiratory status of 6 newborns. Which finding does the nurse report to the health care provider? (Select all that apply.) 1.Respirations 38 breaths per minute at 30 minutes of age. 2.Six-second periods of apnea at 1 hour of age. 3.Grunting at 20 minutes of age. 4.Nasal flaring when the infant is supine. 5.Abdomen and chest rise together for each breath.

1) A respiratory rate of 38 breaths per minute are within the normal range of 30 to 60 breaths per minute. 2) The nurse will report apneic periods of >20 seconds to the health care provider. 3) CORRECT - Grunting at 20 minutes of age is a sign of respiratory distress and will be reported to the health care provider. 4) CORRECT - Nasal flaring when an infant is supine is a sign of respiratory distress and will be reported to the health care provider. 5) It is normal for the abdomen and chest to rise together for each breath.

The nurse provides care for a client with a brain natriuretic peptide (BNP) level of 899 pg/mL. Which priority nursing diagnosis does this finding substantiate? 1.Activity intolerance. 2.Electrolyte imbalance. 3.Risk for injury. 4.Excess fluid volume.

1) A BNP level of 899 pg/mL is significantly above normal finding of <100 pg/mL. The finding indicates acute congestive heart failure, which is a potential nursing diagnosis, but not a priority. 2) Electrolyte imbalance is not a priority nursing diagnosis in acute congestive heart failure. 3) Risk for injury is not a priority nursing diagnosis in acute congestive heart failure. 4) CORRECT - A BNP level of 899 pg/mL indicates acute congestive heart failure. There is excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to acute congestive heart failure. This is the priority nursing diagnosis.

The nurse prepares to administer several units of blood to a client with multiple injuries from a motor vehicle crash. Which device will the nurse use during the transfusions to reduce the risk of cardiac dysrhythmias? 1.Cardiac monitor. 2.Infusion pump. 3.Pulse oximeter. 4.Blood warmer.

1) A cardiac monitor is useful for the early assessment of complications but does not reduce the occurrence of cardiac dysrhythmias. 2) An electronic infusion pump is not helpful in this case because the infusion must be rapid, and an infusion pump is used to control the flow rate. 3) A pulse oximeter is useful for the early assessment of complications but does not reduce the occurrence of cardiac dysrhythmias. 4) CORRECT— When several units of blood are administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias.

The nurse teaches a parent measures to reduce her school-age client's fever. Which information does the nurse include? 1.Sponge the skin with cold water.2.Give aspirin for a fever of 100.4° F (38° C) or higher.3.Cover with warm blankets.4.Apply clothing lightly.

1) Tepid water should be used to prevent shivering 2) Aspirin and aspirin-containing products are not recommended for a child under 19 years of age with a fever because of a possible risk for Reye syndrome. 3) Warm blankets should be avoided with a fever. Evaporative heat loss is needed. 4) CORRECT - Clothing should be applied lightly to allow for evaporative heat loss.

The nurse provides care for a client with a morphine addiction. Which symptom of withdrawal does the nurse expect to assess in the client? (Select all that apply.) 1.Constipation.2.Diarrhea.3.Hypertension.4.Hypotension.5.Emesis.

1) Constipation occurs during morphine use because opioids decrease intestinal peristalsis and increase the tone of the anal sphincter. 2) CORRECT - Diarrhea is due to a rebound excitability of the bowels that have been depressed during morphine use. 3) CORRECT - Hypertension is a rebound effect of the hypotension that occurred while using morphine. 4) Hypotension is a side effect of morphine use because opioids cause peripheral blood vessel dilation. 5) CORRECT - Vomiting, or emesis, occurs due to the rebound effects on the gastrointestinal tract that include changes in stomach tone and increased peristalsis.

The nurse is assigned to care for several clients. Which client will the nurse monitor closely for delirium? 1.A middle-aged adult client admitted 2 hours ago due to a fall after drinking four alcoholic beverages. 2.An adult client, who is 1-day post exploratory laparotomy, reporting thirst. 3.An older adult client diagnosed with Alzheimer disease who has vomiting and diarrhea. 4.An adult client who is in the hospital for preop testing for elective cataract surgery.

1) Alcohol withdrawal symptoms such as delirium manifest later than 2 hours after last drink. 2) Thirst is not a predictor of postop delirium; electrolyte and dehydration imbalance are. 3) CORRECT— Older adult clients with dementia and acute medical issues are at greatest risk for delirium. 4) A stable client is not at risk for delirium.

The nurse provides care for a client diagnosed with a pressure injury wound on the sacrum. Which client care activity is appropriate to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1.Set up supplies for use in the dressing change. 2.Choose the right dressing for wound treatment. 3.Measure the wound size and depth and notify nurse. 4.Reposition the client at least every 2 hours. 5.Assist the client with adequate food and fluid intake.

1) CORRECT — Setting up supplies is within the scope of practice of NAPs. 2) Selecting the right dressing is done by the nurse, based on assessment of the wound. 3) Measuring the wound is an assessment that the nurse does. 4) CORRECT — Repositioning the client independently as directed by the nurse is within the scope of practice of NAPs. 5) CORRECT — Assisting clients with food and fluid intake is within the scope of practice of NAPs.

The nurse assess a pregnant client at 10 weeks gestation. Which finding is consistent with the gestational age of the fetus? 1.A ballottement occurs during a pelvic examination.2.A fetal heartbeat can be heard with a Doppler.3.The systolic blood pressure has increased 15 mm Hg above baseline.4.The client reports feeling quickening in the lower abdomen.

1) A sudden tap on the cervix during vaginal examination may cause a fetus to rise in amniotic fluid and then rebound to original position. This is referred to as a ballottment and occurs near mid-pregnancy, not at 10 weeks. 2) CORRECT - The fetal heartbeat may be detected as early as 10 weeks using a Doppler device. 3) The mother's systolic pressure would not expect to increase at this point in the pregnancy. This is not an expected finding. 4) Quickening, a fetal movement felt by mother, is first perceived at 16 to 20 weeks as a faint fluttering in the lower abdomen.

The nurse develops a teaching plan for a client diagnosed with heart failure. Which information does the nurse include? 1.Tell the client to notify the health care provider of a weight gain of 1 pound a week. 2.Teach the client to monitor urine output for changes in color. 3.Encourage the client to check blood pressure every 4 hours. 4.Advise the client to have flu and pneumococcal immunizations.

1) A weight gain of a pound a week is not clinically significant. A weight gain of 2 or more pounds per day is reportable. 2) Changes in urine color are not a reliable indicator of relevant clinical changes. 3) Self-monitoring of blood pressure every 4 hours is not evidence-based practice. 4) CORRECT — Flu and pneumonia create a greater hemodynamic burden and lead to higher mortality. The Centers for Disease Control and Prevention (CDC) recommends flu and pneumonia immunizations for clients with heart failure and all chronic diseases.

The nurse provides care for an older adult client with stage IV colon cancer. The health care provider has just told the client there is no further curative treatment available. The client is tearful. When the client asks for the name of "a better health care provider," the nurse recognizes that the client is in which stage of grief as described by Kübler-Ross? 1.Acceptance. 2.Denial. 3.Anger. 4.Bargaining.

1) Acceptance is the stage in which the client acknowledges the finality of the situation. The client is neither angry nor depressed. 2) CORRECT - Denial is the stage in which the client is in disbelief of the situation and may request a second opinion. 3) Anger is the stage in which the client may experience rage and resentment toward the situation, the health care team, and/or God. 4) Bargaining is the stage in which the client and/or family plead for more time and may make deals with God.

The nurse provides care to a client who is at a high risk for falling. Which medication will the nurse identify that increases the client's risk? (Select all that apply.) 1.Acetaminophen. 2.Hydrocodone. 3.Diphenhydramine. 4.Lorazepam. 5.Lisinopril.

1) Acetaminophen is an analgesic/antipyretic and does not increase the risk of falling. 2) CORRECT - Hydrocodone is an opioid and has the side effects of sedation, hypotension, drowsiness, and dizziness, which can increase the risk of falls. 3) CORRECT - Diphenhydramine is an antihistamine/anticholinergic with side effects that include dizziness, drowsiness, hypotension, and sedation. These effects increase the client's risk for falling. 4) CORRECT - Lorazepam is a sedative. The side effects of this medication may include drowsiness, hypotension, ataxia, and confusion, all of which can increase the client's risk for falling. 5) CORRECT - Lisinopril is an angiotensin converting enzyme inhibitor that has the side effects of dizziness and orthostatic hypotension. The client's risk for falling is increased with this medication.

The nurse plans a program about health maintenance for a group of older adults in the community. Which recommendation is most appropriate for the nurse to teach? 1.Avoiding aerobic exercise.2.Consuming a vegetarian diet.3.Avoiding manual labor.4.Using screening services.

1) Aerobic exercise must be encouraged unless there is a medical contraindication. 2) A vegetarian diet is not necessary to stay healthy, although it may be a lifestyle choice. 3) There is no contraindication for older adults to do manual labor. 4) CORRECT - Secondary prevention is important in helping older adults live a healthy life. It includes the use of screening services to identify issues early so they can be addressed before long-term complications arise.

The nurse notifies Meals on Wheels to begin delivering daily meals to the home of an older client. Which information does the nurse use to make this referral? 1.An adult child visits the home twice a week. 2.Family members who live in the home work during the night. 3.The client is returning home after surgery and lives alone. 4.Adolescent grandchildren who live in the home have part-time jobs.

1) An adult child visiting twice a week does not mean that the client does not have adequate food in the home or is unable to obtain food. 2) Because family members are present, the client most likely has access to food regardless of when the family members go to work. 3) CORRECT— The client is recovering from surgery and lives alone. The client needs time to fully recover and may not be able to access or obtain food. It may be difficult for the client to prepare food, depending on the type of surgery and length of recovery time required. 4) Living with adolescents indicates that there are other people in the household with the older client. Even though the children have part-time jobs, there is no reason to believe that the client does not have access to or is unable to obtain food.

The magnetic resonance imaging report for a comatose client with a traumatic brain injury (TBI) states that forces disrupted the structure of neurons and nearby blood vessels. Which type of TBI will the nurse suspect this client experienced? 1.Epidural hematoma.2.Concussion.3.Subarachnoid hemorrhage.4.Diffuse axonal injury.

1) An epidural hematoma occurs in the space between the dura mater and skull. 2) A concussion is a mild traumatic brain injury caused by blunt trauma to the head. With this injury there is no apparent structural damage to the brain and it does not result in a coma. 3) A subarachnoid hemorrhage is an accumulation of blood or hematoma between the meningeal arachnoid layer and the brain. 4) CORRECT— In a diffuse axonal injury, axons in the cerebral hemispheres, corpus callosum, and brain stem are damaged. This typically results from high-speed acceleration, deceleration, or a rotational injury from a motor vehicle crash. Bleeding may or may not be present, but global cerebral edema is present.

The nurse assesses a 4-hour-old newborn for acrocyanosis. Which finding does the nurse expect? (Select all that apply.) 1.Blue extremities rated "1" for color on the Apgar Score.2.Cyanosis of the trunk and thoracic region.3.Cyanosis of the hands and feet.4.Color returns quickly after blue area is blanched.5.Cyanosis of the lips and mucous membranes.

1) CORRECT - A score of "1" is given in the color category, even though acrocyanosis is a common, normal variation. 2) The trunk and thoracic region should not be cyanotic. This indicates central cyanosis. 3) CORRECT - Cyanosis in distal areas due to poor peripheral circulation is a common, normal variation and will be exacerbated if the newborn is cold. 4) CORRECT - Color return after blanching indicates adequate central circulation. 5) Cyanosis of the lips and mucous membranes are characteristics of central cyanosis, which indicates hypoxemia and respiratory distress.

The nurse provides care to clients on a progressive care unit. Which client does the nurse see first? 1.The client recovering from a transjugular intrahepatic portosystemic shunt (TIPS) procedure. 2.The client who received subcutaneous insulin to treat a blood glucose of 317 mg/dL. 3.The client newly diagnosed with systemic lupus erythematosus (SLE). 4.The client receiving continuous octreotide infusion to treat portal hypertension.

1) CORRECT - After a TIPS procedure the client is at risk for bleeding. This client's clotting factors are likely to be altered due to liver dysfunction. The procedure shunts blood away from esophageal varices and requires an assessment by the nurse. 2) The client who received an insulin injection for an elevated blood glucose level is in no acute distress. 3) The client with SLE is in no acute distress. 4) The client receiving octreotide for portal hypertension is in no acute distress.

The nurse performs a preoperative assessment on a client scheduled for aortic valve replacement surgery. Which finding causes the nurse the most concern? (Select all that apply.) 1.Report of allergies to bananas, kiwi, and avocados.2.History of a rash on the hands that lasted more than 1 week.3.High-pitched diastolic murmur present on auscultation.4.Report of weakness that occurs with activity.5.History of swelling, itching, and hives after contact with a balloon.

1) CORRECT - Allergies to bananas, kiwi, or avocados are common in clients with latex allergy. Latex allergy protocol should be followed for this client. 2) CORRECT - A history of a rash on the hands that lasted more than 1 week may indicate a latex allergy. The latex allergy protocol should be followed for this client. 3) A high-pitched diastolic murmur is an expected sign of aortic valve disease. 4) Weakness with activity is expected in clients who require aortic valve replacement surgery. 5) CORRECT - A history of swelling, itching, and hives after contact with a balloon may indicate a latex allergy. The latex allergy protocol should be followed for this client.

The nurse assesses a client with glaucoma. Which clinical manifestation will the nurse expect to find? (Select all that apply.) 1.Cloudy, blurry vision. 2.Artificial lights appear to have rainbows around them. 3.Decreased color perception. 4.Decreased peripheral vision. 5.Headache.

1) CORRECT - Altered vision occurs in glaucoma because of increased ocular pressure. 2) CORRECT - Visual changes occur in glaucoma because of an increase in ocular pressure. 3) Changes in color perception occur in cataracts, not in glaucoma. 4) CORRECT - A decrease in visual fields occurs because of glaucoma-related changes in the eyeball. 5) CORRECT - Increased pressure within the eye can cause a headache.

The nurse reviews laboratory data for a client taking zidovudine. Which result will the nurse report to the health care provider? 1.Hemoglobin 10.5 g/dL (105 g/L). 2.Lactic acid 20 mg/dL (2.0 mmol/L). 3.Erythrocyte sedimentation rate 17 mm/hr. 4.Serum potassium 4.7 mEq/L (4.7 mmol/L).

1) CORRECT - An adverse effect of zidovudine is anemia. A hemoglobin level below normal range could indicate the development of anemia and should be reported. 2) Rare cases of fatal lactic acidosis have been reported in clients taking zidovudine. The client's lactic acid level is within normal limits. 3) The erythrocyte sedimentation rate is used to diagnose an acute infection. (The convention units and SI units are the same value.) Values between 0 and 30 mm/hr are within normal limits. 4) Zidovudine does not affect serum potassium levels. The value listed is within normal limits.

The nurse prepares to make an initial home care visit to a client newly diagnosed with end-stage heart failure. Which action will the nurse take before visiting the client? (Select all that apply.) 1.Evaluate the safety of the client's neighborhood. 2.Determine nursing diagnoses for the client. 3.Establish desired outcomes for the client. 4.Collect information about the client's diagnosis and treatment. 5.Arrange the visit at a time when it is safe to be in the area.

1) CORRECT - During the pre-entry phase, which occurs before the initial visit, the nurse evaluates the safety of the neighborhood where the client lives. 2) During the second, or entry phase, of the home visit, the nurse determines nursing diagnoses. 3) During the second, or entry phase, of the home visit, the nurse, in collaboration with the client and family, establishes desired outcomes. 4) CORRECT - Before the initial visit, the home care nurse collects as much information as possible about the client's diagnosis, surgical experience, socioeconomic status, and prescribed treatments. 5) CORRECT - During the pre-entry phase, which occurs before the initial visit, the nurse arranges the visit at a time when it is safe to be in the area.

An adult child asks the nurse to provide the same medication that was used before to "dry up the gurgling sounds" that the client is making at end-of-life. Which medication will the nurse use to reduce the client's secretions? 1.Scopolamine.2.Nitroprusside.3.Salmeterol.4.Nebivolol.

1) CORRECT - Scopolamine is an anticholinergic agent used in end-of-life care to reduce the production of secretions. 2) Nitroprusside is a vasodilator and is of no benefit in managing end-of-life secretions. 3) Salmeterol is a long-acting beta 2 adrenergic agonist used in the management of asthma. 4) Nebivolol is a beta 1 adrenergic-blocking agent used in the management of hypertension.

The nurse provides care to an older client whose spouse died 6 months ago. Which behavior indicates to the nurse that the client is coping effectively? (Select all that apply.) 1.Shows the nurse family photographs.2.Keeps bi-weekly haircut appointments.3.Visits the spouse's grave every 2 weeks.4.Attends church every week.5.Watches television constantly.

1) CORRECT - Sharing photographs indicates normal grieving behavior. 2) CORRECT - Keeping appointments indicates normal progression through the grieving process. 3) CORRECT - Visiting the grave of the deceased spouse is normal behavior after the death of a loved one. 4) CORRECT - Attending religious services indicates normal grieving behavior. 5) Watching television constantly indicates extreme behavior rather than normal grieving.

The nurse provides care for a client who begins nutritional therapy with parenteral nutrition. The client reports feeling anxious and restless. Which action does the nurse take to prevent the client from being injured? 1.Secure all connections in the system. 2.Monitor vital signs every two hours. 3.Calculate intake and output every four hours 4.Check blood glucose levels every four hours.

1) CORRECT - Since the client is restless, securing the parenteral nutrition tubing is a priority safety issue to prevent the client from pulling the connections apart. 2) Monitoring vital signs according to agency protocol is important, but does not relate to enhancing the client's safety due to risk for injury. 3) Calculating intake and output according to agency protocol is important, but does not relate to enhancing the client's safety due to risk for injury. 4) Checking blood glucose according to agency protocol is important, but does not relate to enhancing the client's safety due to risk for injury.

The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply.) 1.Consume a diet low in saturated fat. 2.Engage in regular, high-intensity aerobic activity. 3.Stop tobacco use by any possible means. 4.Avoid exposure to second-hand smoke. 5.Consume a diet low in soluble fiber.

1) CORRECT - The client should be encouraged to consume a diet low in saturated fat and high in soluble fiber. 2) The client should be encouraged to increase physical activity by getting regular, moderate physical activity. The goal for most adults is to engage in moderate-intensity aerobic activity (not high-intensity aerobic activity). 3) CORRECT - The client should be encouraged to use any possible means to stop tobacco use, such as counseling, support groups, complementary therapies, and medications. 4) CORRECT - Exposure to second-hand smoke should be discouraged because it increases the risk for heart disease. 5) The client should consume a diet low in saturated fat and high in soluble fiber (not low in soluble fiber).

The nurse provides care for a newborn who is recovering from necrotizing enterocolitis (NEC). Which intervention does the nurse include in the newborn's plan of care? 1.Feed the newborn fresh breast milk. 2.Use droplet transmission precautions. 3.Assess rectal temperature frequently. 4.Place the newborn in a prone position.

1) CORRECT - The use of fresh breast milk is the preference for the newborn who is recovering from NEC. It is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. Also, breast milk is more easily digested than formula. 2) Standard, not droplet, precautions are used for the newborn recovering from NEC. 3) Rectal temperatures are avoided for all newborn clients because of the increased danger of perforation. 4) Newborns recovering from NEC are left undiapered and in a supine or side-lying position to avoid pressure on the distended abdomen and facilitate continuous observation.

The nurse reviews the care plans of several clients. Which client will the nurse assess first? 1.Client with a nursing diagnosis of impaired gas exchange.2.Client with a nursing diagnosis of acute pain.3.Client with a nursing diagnosis of acute confusion.4.Client with a nursing diagnosis of decreased cardiac output.

1) CORRECT - Utilizing Maslow's hierarchy of needs and airway, breathing, circulation (ABCs), impaired gas exchange will be the highest priority. This client should be seen first. 2) Acute pain should be addressed, but is not the highest priority. Pain is considered to be a psychosocial need. Address physical needs first. 3) Acute confusion should be addressed, but is not the highest priority. Confusion is a psychosocial need. Address physical needs first. 4) Decreased cardiac output should be addressed, but is not the highest priority. Airway/ breathing needs come before circulation needs.

The nurse provides discharge instructions for an older adult client with osteoporosis. Which point about exercise is most important for the nurse to include in the teaching? 1.Exercise must include weight bearing activities.2.Avoid exercises that increase the risk of fracture.3.Yoga is useful for flexibility and muscle strength.4.Perform aerobic activities for weight reduction.

1) CORRECT - Weight bearing exercises are beneficial in the treatment of osteoporosis because the bone adapts by building and becoming stronger. 2) The nurse may counsel the client to avoid activities that include jumping, but must be specific about exercises to avoid or the client may avoid all activity. 3) Yoga is useful as part of the overall exercise regimen, but this does not address improving bone strength. 4) Aerobics are good for stamina, overall health, and weight reduction, but this exercise does not resolve osteoporosis. Often, clients with osteoporosis already have a low body mass index.

The nurse receives a report of an elevated vancomycin trough level. The client has a glomerular filtration rate (GFR) of 58 mL per minute. Which action does the nurse take? 1.Inform the health care provider (HCP). 2.Check the client's urine output. 3.Request a renal consultation. 4.Assess for red man syndrome.

1) CORRECT — An elevated vancomycin trough level with an inadequate GFR requires immediate attention by HCP. The client's antibiotic level is toxic and the kidneys are not filtering correctly. 2) It is irrelevant whether the client is currently making urine because the drug's nephrotoxic effects are evident and must be reversed. Oliguria would be a late sign and result in a negative outcome. 3) The HCP requests a renal consult. 4) Red man syndrome is due to rapid infusion of vancomycin.

The nurse assesses an older client for depression. Which risk factor will the nurse associate with depression in an older client? 1.Has chronic pain. 2.Lives alone in own home. 3.Is married. 4.Works part time.

1) CORRECT — Chronic pain increases the risk for depression. 2) Independent living may reduce the risk for depression. 3) Being married may reduce the risk for depression. 4) Working part time may reduce the risk for depression.

The nurse works in a health care organization that has earned the American Nurses Credentialing Center Magnet Recognition status for excellence in nursing. Which component is an indicator of this status? (Select all that apply.) 1.Transformational leadership.2.Structural empowerment.3.Exemplary professional practice.4.Willingness to recommend the agency.5.Innovation.

1) CORRECT — Transformational leadership is one of the Magnet indicators. 2) CORRECT — Structural empowerment is one of the Magnet indicators. 3) CORRECT — Exemplary professional practice is one of the Magnet indicators. 4) Willingness to recommend the hospital/agency is a component of the Hospital Consumer of Assessment of Healthcare Providers and Systems survey. 5) CORRECT — Innovation is one of the Magnet indicators.

The nurse develops a brochure on informed consent. Which information is appropriate for the nurse to include in the brochure? (Select all that apply.) 1.An informed consent should not be obtained until the client has discussed the exact details of the surgery or procedure.2.Witnessing an informed consent means that the nurse verifies that the client is mentally competent.3.The nurse needs to explain the benefits and risks of the procedures that require an informed consent.4.Even if a client has signed a general admission consent, an informed consent is required for the client to have a chest X-ray.5.Acting as a client advocate, the nurse is responsible for ensuring that the client has received adequate information regarding the proposed procedure.

1) CORRECT — Informed consent is permission granted by a client after discussing the exact details of the treatment with the health care provider who will perform the surgery or procedure. 2) CORRECT — By witnessing a client's signing of an informed consent, the nurse verifies that the client is mentally competent and that the signature is that of the client. 3) It is not the nurse's responsibility to explain the benefits and risk of the procedures that require an informed consent. The health care provider needs to do that. 4) General consent forms giving permission for treatment in a hospital are signed by a client before being admitted. An informed consent would not be required for a chest X-ray. 5) CORRECT — The nurse, as a client advocate, is responsible for ensuring that the client has received adequate information regarding the proposed procedure.

The nurse suspects cardiac arrest in a pulseless, unresponsive client. Which nursing action is appropriate? (Select all that apply.) 1.Position the client flat and open the airway.2.Provide the client with a 100% oxygen source.3.Call for help and request the crash cart.4.Auscultate for heart and lung sounds.5.Check client's pupil reaction to light.

1) CORRECT — Maintaining a patent airway is an essential action. 2) CORRECT — Providing 100% oxygen during cardiac arrest is an essential action. 3) CORRECT — Calling for help and for the crash cart is an essential action. 4) Auscultating is not indicated during a cardiac arrest. It is assumed that someone in arrest has nothing to auscultate and this information will not alter the care administered. 5) Assessing pupils is not indicated during a cardiac arrest. Airway, breathing, and circulation must be restored prior to assessing neurological activity.

The nurse provides care for a client who experienced major head trauma. The client is scheduled to receive a bolus enteral feeding. Which is the most important action the nurse takes? 1.Measure intake and output.2.Monitor blood glucose levels.3.Check albumin level.4.Monitor for diarrhea.

1) CORRECT — Monitor for equal intake and output to assess fluid balance before providing enteral feeding. The feeding formulas are hyperosmotic agents, pulling fluid from cells into the vascular bed. A significant alteration in fluid balance will result in a change in intracranial pressure. 2) Monitoring glucose levels is important and can be quickly and efficiently corrected with insulin dosing. 3) The nurse will want to ensure that the feeding is maintaining the albumin level within normal limits, but forgetting to do this will not cause immediate harm. 4) If diarrhea develops, the enteral feeding rate or formula can be adjusted or an antidiarrheal medication can be administered. The nurse will have time to correct this before the fluid imbalance causes harm.

Which activities can the nurse delegate to a nursing assistive personnel (NAP) for a client in the postanesthesia unit (PACU)? (Select all that apply.) 1.Obtaining vital signs. 2.Assisting with positioning. 3.Suctioning the oropharynx. 4.Accompanying client transfer. 5.Measuring urine output.

1) CORRECT — NAPs can obtain vital signs in PACU and report the findings to the nurse. 2) CORRECT— NAPs can help the nurse turn and reposition clients. 3) Oropharyngeal suctioning is the responsibility of the nurse. 4) CORRECT — NAPs can accompany and assist in the transfer of clients from PACU. 5) CORRECT — NAPs can measure urine output and report the findings to the nurse.

A client has a new plaster cast applied for a fractured tibia. Which nursing action ensures that the cast dries appropriately? 1.Reposition the limb every two hours. 2.Turn the limb gently with the fingers. 3.Place the limb on a plastic-encased pillow. 4.Elevate the limb above the level of the heart.

1) CORRECT — Repositioning the limb every 2 hours ensures that the entire cast dries thoroughly. 2) The nurse would use the palms of the hands to turn the limb. Using the fingers can cause indentations in the plaster. 3) A plastic-encased pillow hinders the plaster cast from drying appropriately. 4) Elevating the limb may prevent edema, but will not help dry a plaster cast.

The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions? 1."I should insert the suppository about a half inch into my vagina."2."I should plan to lie on my back with my hips elevated for 5 to 10 minutes after inserting the suppository."3."I should wear a perineal pad if I have some of the melted medication come out."4."If I reuse an applicator, I should wash it with soap and water before I use it again."

1) CORRECT — The suppository should be inserted a minimum of 2 inches for the medication to be effective. 2) The client should recline for 5 to 10 minutes with the hips elevated after inserting the suppository. 3) The client should wear a perineal pad to protect the clothing from drainage or staining. 4) The applicator for the suppository should be cleansed with soap and water prior to reuse.

The nurse provides care for a postoperative client. The nurse notes the client is restless. The client grabs at the incisional area. The nurse notes the client's blood pressure to be 146/96 mm Hg. Which action should the nurse take next? 1.Ask the client to rate the pain level.2.Assess the incisional site.3.Reposition the client.4.Apply ice to the incisional site.

1) CORRECT — These signs and symptoms indicate the client is having pain. Assess the client for pain characteristics and to determine the level of pain. 2) This will not be the next step. The client is exhibiting signs and symptoms of pain that need to be assessed. 3) This will not be the next step. The nurse needs to assess the pain level first before attempting to try nonpharmacological methods of pain control. 4) This will not be the next step. The nurse needs to assess the pain level first before attempting to try nonpharmacological methods of pain control.

The nurse teaches a client with chronic pancreatitis about self-management. Which topics does the nurse include about preventing an exacerbation of pancreatitis? (Select all that apply.) 1.Take the pancreatic enzymes replacements as ordered.2.Avoid pregnancy during the first year of diagnosis.3.Eat a low-fat, high-protein, and moderate carbohydrate diet.4.Maintain alcohol abstinence.5.Consume small meals and snacks.

1) CORRECT- Adherence to the pancreatic enzyme regimen is essential to prevent exacerbations. 2) Pregnancy is not contraindicated in a client with chronic pancreatitis. 3) CORRECT- Diet modifications help prevent flare-ups caused by eating high-fat content foods. 4) CORRECT - Alcohol avoidance prevents further damage to the pancreas and promotes healing. 5) CORRECT- Small meals prevent over stimulation of the pancreas and promote recovery.

The nurse prepares a client for peripheral intravenous catheter placement. Which factor will the nurse consider when inserting the catheter? (Select all that apply.) 1.Avoid extremities with lymph node removal.2.Place intravenous line on side that is paralyzed.3.Choose area closest to wrist.4.Choose nondominant arm if possible.5.Avoid site close to cellulitis.

1) CORRECT— Extremities with lymph node removal should be avoided to prevent the development of lymphedema. 2) Intravenous catheters should not be placed in a paralyzed limb because of alteration in sensation. 3) Areas of flexion and extension, such as the wrist, should be avoided. 4) CORRECT— A nondominant arm prevents displacement of the catheter. 5) CORRECT— Areas of infection should be avoided.

The nurse notes that at 2200, a client is scheduled to receive 10 units of insulin glargine. The client also has a "now" prescription of 7 units of regular insulin. Which approach will the nurse use to administer these medications? 1.Prepare two separate injections.2.Administer the regular insulin first.3.Mix the medications in one syringe.4.Administer the insulin glargine first.

1) CORRECT— Insulin glargine should not be mixed with any other insulin. This client will need two separate injections. 2) There is no evidence to support that the regular insulin should be administered before insulin glargine. 3) Insulin glargine should not be mixed with any other medication. 4) There is no evidence to support that insulin glargine should be administered before the regular insulin.

The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). Which intervention does the nurse expect the health care provider to prescribe? (Select all that apply.) 1.Short acting intravenous (IV) insulin. 2.Isotonic intravenous (IV) fluids. 3.Total parenteral nutrition (TPN). 4.Hourly intake and output. 5.Finger blood glucose every four hours.

1) CORRECT—Regular insulin administered intravenously will lower blood glucose. 2) CORRECT—Isotonic IV fluids replace fluid and electrolytes losses that often occur with DKA. 3) A prescription for TPN is not indicated for this client. 4) CORRECT—Hourly intake and output to monitor hydration status is necessary. 5) Hourly blood glucose check is indicated. Four hours is too long an interval.

The nurse teaches a group of nursing students about informed consent for medical treatment. The nurse includes teaching about informed consent involving minors. Which statement is correct for the nurse to include in the teaching? 1.Minors with cognitive impairment may consent with a parent. 2.Minors in active military service may consent without a parent. 3.Minors who need emergency surgery may sign the consent. 4.Minors who are orphans cannot sign their informed consent.

1) Cognitively impaired persons of any age cannot sign their own consent forms. 2) CORRECT— Minors who are in active military service are considered to be emancipated minors. This legal status allows them to consent to medical treatment on their own accord. 3) In an emergency, consent is not necessary and may not be obtainable quickly enough. 4) Being an orphan does not prevent an emancipated minor from consenting to medical treatment.

The nurse observes a client bearing weight on the axillary pads of crutches when ambulating. Which action does the nurse implement? (Select all that apply.) 1.Suggest using a quad cane. 2.Notify the health care provider. 3.Provide education. 4.Document observation. 5.Consult physical therapy.

1) Crutches are used when one or both legs are unable to bear weight. The purpose of the quad cane is to provide additional balance. Bearing weight on the axillary pads of crutches is incorrect, and the client needs education or a physical therapy consult. Suggesting that the client use a quad cane is inappropriate. 2) Bearing weight on the axillary pads demonstrates incorrect use of crutches and can lead to nerve damage. This nurse needs to provide client education and consult physical therapy. In this situation, contacting the health care provider is incorrect. 3) CORRECT - Bearing weight on the axillary pads of crutches demonstrates incorrect use and can lead to nerve damage. The nurse needs to provide client education on proper use of crutches. 4) CORRECT - Bearing weight on the axillary pads of crutches demonstrates incorrect use and can lead to nerve damage. The nurse needs to document this observation and interventions that were implemented (education). 5) CORRECT - Bearing weight on the axillary pads of crutches demonstrates incorrect use and can lead to nerve damage. The nurse needs to consult physical therapy. Physical therapy can assess the client when ambulating with crutches to determine if the client has the strength needed for crutches and make recommendations, if needed.

A client expresses concern to the nurse about possibly needing blood during an upcoming surgical procedure. Which action will the nurse suggest to reduce the risk of a transfusion complication? (Select all that apply.) 1.Drink extra fluids before the surgery to increase blood volume.2.Ask a family member to do a directed blood donation for the client.3.Take iron supplements to increase hemoglobin and hematocrit levels.4.Schedule an autologous blood donation before the surgery.5.Take large amounts of vitamin C several weeks prior to surgery.

1) Drinking extra fluid will not sufficiently increase blood volume to reduce the need for a transfusion. 2) CORRECT — The next most effective way to reduce the risk of a transfusion complication, other than autologous blood donation, is to ask a family member to donate blood before surgery. 3) Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. 4) CORRECT — Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. 5) Vitamin C enhances iron absorption, but it is not helpful in replacing blood lost during surgery.

The nurse is teaching a group of individuals about nutrition. Which information is appropriate for the nurse to include? 1.The client who is 20 weeks gestation should add 500 calories to the daily intake. 2.The client with emphysema should drink eight to ten 8-oz. glasses of water per day. 3.The child who is 1 year of age should drink fat-free milk. 4.The client with diverticulosis should limit the intake of high-fiber foods to 20 grams per day.

1) During the first trimester of pregnancy, no added calories are needed. However, the daily caloric intake for pregnant women should increase by 340 calories during the second trimester and 452 calories during the third trimester. Adding 500 calories per day is too much. 2) CORRECT— To assist in airway clearance the client needs to be well hydrated. Fluid intake is 2 to 3 liters per day unless contraindicated. Adequate hydration promotes mucus clearance because pulmonary secretions are thin, white, watery, and easily removed with minimal coughing. 3) Skim milk and reduced-fat milk deprive the infant of needed calories and essential fatty acids. Skim milk is appropriate beginning at 2 years of age. 4) A diet high in fiber, mainly from fresh fruits and vegetables, and a decreased intake of fat and red meat are recommended for diverticulosis.

The nurse instructs a client newly diagnosed with diverticular disease. Which statement indicates to the nurse that additional teaching is required? (Select all that apply.) 1."I should eat food high in fiber." 2."I should drink plenty of fluids every day." 3."I should eat red meat several times a week." 4."I should eat a diet high in fat and carbohydrates." 5."I should limit alcohol intake to several times a week."

1) Fiber reduces the risk of outpouching in the colon. 2) Eight, or more, 8-ounce glasses of water a day reduces the risk of constipation. 3) CORRECT — It is recommended to limit the intake of red meat to reduce the risk of constipation. 4) CORRECT — A low-fat diet reduces risk of symptoms and constipation. A balanced diet of carbohydrates, proteins, fats, and fiber is recommended for most clients. 5) CORRECT — A client should avoid alcohol as it can irritate the lining of the gastrointestinal tract and exacerbate symptoms of diverticular disease.

The nurse provides care for a client experiencing supraventricular tachycardia (SVT). Which action by the nurse is appropriate when giving adenosine? 1.Inject over 1 minute, followed by a normal saline flush (NS).2.Inject over 1 to 3 seconds, followed by a normal saline flush.3.Inject over 2 minutes using an intravenous (IV) pump.4.Inject over 10 seconds while doing cardiac compressions.

1) Giving adenosine over 1 minute is ineffective. 2) CORRECT — To maximize efficacy, inject over 1 to 3 seconds, followed with a 20 mL NS flush. 3) Use of an IV pump is not appropriate. 4) Cardiac compressions are not indicated because the client is in SVT, an organized rhythm.

The nurse provides care for a 12-month-old infant. The infant's parent states to the nurse, "My baby sleeps 18 hours a day; 14 hours at night and a 4 hour nap." Which action does the nurse take next? 1. Let the parent know this is normal for the infant's age.2. Instruct the parent to cut back on the time the infant naps.3. Notify the health care provider.4. Instruct the parent to put the infant to bed earlier at night

1) Infants up to age 2 do sleep 12 to 15 hours, but 17 hours is more than normal and should be reported to the health care provider. 2) Cutting back on nap times will not decrease overall infant sleep time. The infant may sleep more at night as as result. The infant is already sleeping 14 hours at night. 3) CORRECT - The infant could have an underlying medical condition causing excessive sleep. This situation should be reported to the health care provider. 4) Increasing nighttime sleep will not reduce the overall sleep time of the infant. 17 hours is more than normal and should be reported to the health care provider.

The nurse plans to assess a client with acquired immune deficiency syndrome (AIDS). Which question provides the least amount of information to plan this client's care? 1.What method of birth control do you use?2.Do you use intravenous drugs?3.How many sexual partners do you have?4.How old were you when you became sexually active?

1) Information about birth control is important to prevent a baby from being born with the AIDS virus. 2) Intravenous drug use is a risk factor for AIDS. 3) Sexual partners is a risk factor for AIDS. 4) CORRECT - Asking about the age when sexual activity started is not relevant because it does not provide any information related to the presence of risk factors for AIDS.

The nurse teaches an accident prevention class for parents of school-age children. Which factor will the nurse list as causing the most accidental injuries in school children? 1.Lack of parental supervision.2.Physical awkwardness and clumsiness.3.Peer pressure and risk-taking behaviors.4.Impressing members of the opposite gender.

1) Lack of parental supervision is not the primary factor in accidental injuries. 2) Physical awkwardness and clumsiness is more characteristic in adolescence than in school-age children. 3) CORRECT — School-age children take risks trying to impress friends and to fit into the peer group. 4) Impressing members of the opposite gender is usually more characteristic of children of high school age.

The nurse provides care for a client who is severely withdrawn. Which medication will the nurse expect to be prescribed for this client? 1.Lorazepam. 2.Chlordiazepoxide. 3.Phenytoin. 4.Citalopram.

1) Lorazepam is a benzodiazepine that is used to treat anxiety. 2) Chlordiazepoxide is a benzodiazepine that is used to treat anxiety. 3) Phenytoin is an anticonvulsant that is used to treat seizures. 4) CORRECT — Citalopram is a serotonin uptake inhibitor that is used to treat depression.

The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teaches the client about the diagnosis. Which property of benign tumors should the nurse include in the teaching? 1.They are poorly differentiated.2.They metastasize to other organs.3.They grow at an aggressive rate.4.They can cause tissue destruction.

1) Malignant tumors are poorly differentiated. Benign tumors are more differentiated, meaning they more closely resemble the cells of the tissue from which they arose. 2) Benign tumors are not able to metastasize. 3) Not all tumors, benign or malignant, grow aggressively; some are indolent, or slow growing. 4) CORRECT - Benign tumors can cause tissue destruction by the size and location in the body.

The nurse provides care to four clients. For which client illness will the nurse use an N95 disposable respirator? 1.Pneumocystis pneumonia (PCP) with fever. 2.Varicella lesions with drainage. 3.Bordetella pertussis with cough. 4.Norovirus with projectile emesis.

1) PCP is caused by Pneumocystis jirovecii and is an opportunistic infection commonly affecting those with extremely poor immune systems, such as those with acquired immunodeficiency syndrome (AIDS). This organism does not pose a hazard requiring transmission precautions. 2) CORRECT — Active chicken pox, or varicella, requires airborne transmission precautions, including a fit-tested N95 respirator, until the lesions are dried or crusted. 3) Pertussis, or whooping cough, requires droplet transmission precautions, including the use of a surgical mask. 4) Norovirus requires contact transmission precautions, which may include a face shield if fluid contact is anticipated.

During an assessment the nurse suspects that an injured child is a victim of physical abuse. Which action is the nurse's primary legal responsibility in this situation? 1.Refer the family to the hospital social worker.2.Call the hospital attorney to report the suspicion.3.Report the case to the local law enforcement authorities.4.Document the physical assessment of the child accurately and thoroughly.

1) Referring the family to the hospital social worker is not the nurse's legal responsibility. 2) It is not the nurse's legal responsibility to report the suspicion to the hospital attorney. 3) CORRECT — Nurses are obligated to report suspected child abuse to local authorities. 4) This is the nurse's professional responsibility, but the primary legal responsibility is to report the abuse to the local authorities.

The nurse creates a care plan for a client who has a stage 3 pressure injury. Which nursing diagnosis should the nurse assign as the highest priority for this client? 1.Risk for infection. 2.Imbalanced nutrition, less than body requires. 3.Altered health maintenance. 4.Impaired skin integrity.

1) Risk for infection would not be the highest priority because it is a risk diagnosis. The client does not show any signs or symptoms of infection. 2) Imbalanced nutrition, less than body requires is not the highest priority because there is not supporting data in the scenario to indicate the client is malnourished. 3) Altered health maintenance is not the highest priority. Impaired skin integrity will be a higher priority than altered health maintenance. 4) CORRECT - The scenario states the client has a stage 3 pressure injury. The interventions surrounding care for the wound will be the highest priority.

The nurse provides care to a client receiving mechanical ventilation for 4 days. Which action will the nurse use to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) 1.Change the ventilator tubing once a shift.2.Elevate the head of the bed 30 to 45 degrees.3.Wear a surgical mask during suctioning.4.Perform daily spontaneous breathing trials.5.Drain condensation from the ventilator tubing.

1) Routine changing of ventilator tubing based of duration of use is not indicated in preventing VAP. 2) CORRECT - Positioning with the head of the bed elevated to 30 degrees or higher significantly reduces gastric reflux and VAP. 3) Wearing a surgical mask during suctioning of a mechanically ventilated client is not indicated to prevent VAP. 4) CORRECT - Daily spontaneous breathing trials promotes weaning and decreases the risk for VAP. 5) CORRECT - Draining condensation from ventilator tubing reduces the risk for aspiration of fluid into the lungs and the spread of infection.

The nurse teaches a group of clients about skin cancer prevention. Which statement does the nurse include in the teaching? (Select all that apply.) 1.Avoid sun exposure between 1600 and 1800.2.Wear opaque clothing and a hat when outside.3.Have genetic testing to assess skin cancer risk.4.Keep a "body map" of skin spots for a baseline.5.Restrict shaving of arms and lower extremities.

1) Sun exposure should be avoided between 1100 and 1500. 2) CORRECT - Opaque clothing protects the skin from direct sun exposure. 3) There is no genetic testing available for skin cancer. 4) CORRECT - Being aware of skin markings and spots allows the client to note changes. 5) Not shaving the arms and legs has no skin cancer protective effect.

The nurse on the postpartum unit makes client care assignments. Which client care task does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.) 1.Clearing the volume infused on an intravenous fluid pump.2.Emptying the urine from an indwelling urinary catheter bag.3.Assessing the characteristics and amount of lochia.4.Documenting the amount of oral fluid intake.5.Assisting a post-cesarean section client to the shower.

1) The NAP may not change settings on the IV pump, including clearing the volume. It is outside the scope of practice. 2) CORRECT - The NAP can empty the bag of an indwelling urinary catheter and document the amount. 3) The NAP may not assess. It is outside the scope of practice.. 4) CORRECT - The NAP may document oral intake. 5) CORRECT - The NAP may assist a postoperative, postpartum client to the shower. There is no indication that the client is unstable.

The nurse provides care to a client with a deep vein thrombosis (DVT). Which nursing diagnosis will the nurse designate as most appropriate for this client? 1.Impaired gas exchange related to increased blood flow.2.Risk for injury related to edema.3.Fluid volume excess related to peripheral vascular disease.4.Altered peripheral tissue perfusion related to venous congestion.

1) The blood flow in thrombosis is decreased, not increased. There is no evidence of impaired gas exchange. 2) Risk for injury is possible. However, it would be secondary to altered tissue perfusion. 3) There is no evidence to support that this client has a fluid volume excess. 4) CORRECT - Venous inflammation and clot formation impedes blood flow in a DVT. This is the nursing diagnosis that should be a priority.

The charge nurse takes a brief report from a nurse assigned to a client just admitted with a deep vein thrombosis (DVT). Which statement requires immediate follow up by the charge nurse? 1.The client's left leg is warm, enlarged, and painful.2.The client ambulated to the bathroom without difficulty.3.The client plays tennis weekly.4.The client has a history of bipolar disorder and depression.

1) The client admitted for a deep venous thrombosis (DVT) is expected to experience symptoms of a DVT, such as a warm, swollen, and painful extremity. 2) CORRECT - The client should not ambulate until the DVT is resolving well, which usually takes a few days. Evidence that the client is anticoagulated, such as coagulation lab values, is also needed. 3) It is not relevant that the client normally plays tennis. 4) The client's history of a mental health disorder needs follow up to ensure the correct medications are prescribed, but it is not the immediate concern.

The nurse provides care for a client admitted with fever, headache, chills, cough, and malaise. Which personal protective equipment (PPE) does the nurse wear to provide care to the client? 1.Gloves and gown. 2.N-95 respirator mask. 3.Mask. 4.Gloves.

1) The client displays signs of influenza, which is spread through respiratory droplets. Therefore, a mask should be worn when caring for the client. A gown and gloves are indicated for contact precautions to prevent the spread of infection through direct contact with the client or the client's environment. 2) An N-95 respirator mask is indicated for airborne isolation precautions. Airborne precautions are indicated to prevent the spread of infection through droplet nuclei. 3) CORRECT - The client shows signs of influenza. In addition to standard precautions, the nurse should institute droplet precautions, which require the use of a mask when in close proximity to the client. 4) Gloves are indicated when contact with blood or body fluids is likely.

The adult children of a client recovering from stem cell transplantation bring a bag of home-prepared food for the client, including a salad with toppings. Which statement does the nurse make before the family enters the client's room? 1."I'm sure this food from home is going make the client feel better." 2."There's nothing like a fresh salad to help with vitamins and minerals!" 3."I know your parent likes blue cheese, but it cannot be eaten at this time." 4."Be sure all fresh vegetables are washed before taking them into your parent's room."

1) The client is in protective isolation and may be on a specific diet after the transplant. 2) No fresh raw fruit or vegetables may be brought into a protective isolation room because they may harbor bacteria and fungi. 3) CORRECT - No blue cheese may be brought into a protective isolation room because it may harbor bacteria and fungi. 4) No fresh raw fruit or vegetables, regardless of when they were washed, may be brought into a protective isolation room because they may harbor bacteria and fungi.

A client with a history of lung cancer coughs, sits forward, uses accessory muscles to breathe, and has facial and upper extremity edema. Which action will the nurse perform? (Select all that apply.) 1.Assist client to ambulate in the hallway twice daily. 2.Instruct client to maintain semi- to high-Fowler position. 3.Record neurological status every 4 hours. 4.Monitor pulse oximetry continuously. 5.Encourage client to increase fluid intake.

1) The client needs to conserve energy and this amount of ambulation may compromise oxygenation. 2) CORRECT — The client is demonstrating signs of superior vena cava syndrome (SVCS) and needs to stay upright to reduce pressure in the trunk, neck, and head vasculature. 3) CORRECT — Superior vena cava syndrome (SVCS) can cause neurological changes and progress to cerebral anoxia. 4) CORRECT — Superior vena cava syndrome (SVCS) can cause deterioration in oxygenation due to obstructing venous drainage. 5) Venous overload occurs in Superior vena cava syndrome (SVCS) due to obstruction of venous drainage. Increasing fluids may make the symptoms of SVCS worse.

A client with septic shock requires central venous access catheter insertion for administration of vasoactive drugs. Which step will the multidisciplinary team take to reduce the client's risk for central line-associated bloodstream infection? (Select all that apply.) 1.Use a femoral insertion site.2.Prepare the insertion site with chlorhexidine.3.Use maximal barrier precautions during insertion.4.Perform hand hygiene before insertion.5.Use a checklist to guide insertion.

1) The femoral insertion site should be avoided because of the increased risk of central line-associated bloodstream infection. 2) CORRECT - Chlorhexidine is more effective than other antiseptic agents, such as povidone iodine solution. 3) CORRECT - Maximal barrier precautions reduce the risk of central line-associated bloodstream infection. 4) CORRECT - Hand hygiene is a key element in reducing the risk of central line-associated bloodstream infection. 5) CORRECT - An insertion checklist ensures that safety measures are followed to reduce the risk of central line-associated bloodstream infection.

The nurse provides care to a client whose insurance coverage is Medicare. Which understanding will the nurse have about Medicare before planning care for this client? 1.The hospital will be paid for the full cost of the client's hospitalization. 2.Medicare will pay the hospital the national average cost for the client's condition. 3.Diagnosis-related groups provide a fixed reimbursement of cost. 4.Capitation provides the hospital with a means of recovering variable charges.

1) The hospital is paid based on a diagnosis-related group system, so a specific amount is paid based on the case severity and the rural/urban/regional standard rates. 2) The reimbursement is based on case severity, rural/urban/regional costs, and teaching costs, not national averages. 3) CORRECT - Medicare uses a fixed reimbursement amount based on assigned diagnosis-related group, regardless of a patient's length of stay or use of services. Diagnosis-related group reimbursement is based on case severity, rural/ urban/ regional costs, and teaching costs, not national averages. 4) Capitation means that providers receive a fixed amount per patient or enrollee in a health care plan.

An adolescent client is brought to the hospital with a head injury requiring emergency surgery. The client's parents are out of the country. The client is staying with the paternal grandparents. The nurse identifies which source as legal consent for surgery? 1.The parents by phone.2.The attending surgeon.3.The paternal grandparents.4.The hospital lawyer.

1) The parents may or may not be available by phone. Valuable time may be wasted trying to reach the parents. The grandparents can give legal consent. 2) If no family members are available and the client's condition is life-threatening, the surgeon can perform surgery with assumed consent. 3) CORRECT- Any grandparent can give consent for a minor grandchild in an emergency, if the parents are not present. 4) The hospital lawyer does not have the authority to give consent for the minor to have surgery.

The nurse provides care for a toddler who is a ward of the state. The toddler requires surgery. Who is authorized to give written, informed consent for the procedure? 1.Primary care health care provider.2.Nurse manager.3.Foster parent.4.Social worker who placed the child in the foster home.

1) The primary health care provider has no legal authority in this matter. 2) The nurse manager is not legally able to sign the consent form. 3) CORRECT - When children are minors, aren't emancipated, and the parents do not have custody, the designated legal guardians are responsible for providing consent for medical procedures. For this child, the legal guardians are the foster parents. 4) The social worker has no legal authority in this matter.

The nurse discharges a client diagnosed with Parkinson disease to live at home with the family. Which teaching will the nurse provide as part of this client's discharge? (Select all that apply.) 1.Provide intermittent oral suctioning for aspiration precautions. 2.Arrange for sides of bed to be padded for seizure precautions. 3.Keep bed at lowest position.4.Wear surgical masks for neutropenia precautions. 5.Use non-skid socks for fall precautions.

1) There is no indication that the client will need suctioning. 2) There is no indication that the client should be on seizure precautions. 3) CORRECT— Keeping the bed in the lowest position prevents falls and would be appropriate for this client. 4) There is no indication that this client needs to be on neutropenia precautions. 5) CORRECT — The client with Parkinson disease ambulates with a shuffling gait. Non-skid socks would be appropriate to prevent falls.

A client experiencing insomnia asks if there are any dietary modifications that can help improve sleep. Which response by the nurse is best? 1.Eat small portions throughout the day.2.Limit alcohol in the late afternoon and evenings.3.Restrict fluid intake to five liters per day.4.Reduce daily intake of salt and sugar.

1) There is no scientific evidence that eating small portions can improve sleep. 2) CORRECT - The diuretic effect of alcohol can cause the client to awaken from sleep to void. Limiting alcohol intake can improve sleep. 3) Fluid restriction does not improve sleep quality. 4) Salt and sugar reduction is part of general wellness. They are not associated with improved sleep.

The nurse provides care for a client after an above the knee amputation (AKA) 2 days ago. The nurse places the client in which position? 1.Reverse Trendelenburg position.2.Prone position.3.Lithotomy position.4.High Fowler position.

1) This position does not prevent hip contracture and may greatly increase edema. 2) CORRECT — The client is placed in the prone position for a short time on the first postoperative day and then for 30 minutes three times a day to stretch the flexor muscles and prevent hip contracture. 3) This position does not prevent hip contracture. 4) This position does not prevent hip contracture but may actually cause it.

The nurse provides care for a client diagnosed with multiple myeloma. The client's new pain management regimen includes timed-release oxycodone and immediate-release oxycodone. The client asks the nurse how to schedule these new medications. Which response by the nurse is best? 1."Take the timed-release medication every morning and evening." 2."Take the immediate-release medication any time that you are hurting." 3."Schedule the medication close to bedtime in case it makes you sleepy." 4."Schedule both medications so that your pain is relieved all day."

1) This response does not address the schedule for the immediate-release narcotic. 2) This response does not address the schedule for the extended-release narcotic. 3) This response is inaccurate. Extended-release medications do not have immediate effects like sleepiness, but immediate-release medications might, and this leaves the client without pain relief all day. 4) CORRECT — The client needs to schedule the medications so that around the clock stable analgesic control is achieved.

The nurse prepares a client with macular degeneration for surgery. Which preoperative goal is most important for this client? 1.Client will use a bedpan for elimination needs.2.Client will independently ambulate around the unit.3.Client will maneuver safely after orientation to the room.4.Client will read the preoperative education materials.

1) Using the bedpan is an unnecessary restriction on the client, as the client can be oriented to the bathroom or to call for assistance. 2) Independently ambulating around the unit is not appropriate because the unit environment can change and the client could be injured. 3) CORRECT - Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client ambulate safely. 4) It is unlikely that the client can see well enough to read the materials.

The nurse prepares a teaching plan on acute leukemia. Which common sign and symptom of acute leukemia should the nurse include in the plan? (Select all that apply.) 1.Weight gain.2.Petechiae.3.Orthostatic hypotension.4.Joint pain.5.Bradycardia.

1) Weight loss, not weigh gain, is commonly seen due to eating difficulties. 2) CORRECT - Due to anemia, petechiae will appear on the skin. 3) CORRECT - The clotting abnormality and anemia can cause orthostatic hypotension. The client should rise slowly from a lying to a sitting or standing position. 4) CORRECT - Joint pain is due to bleeding and expansion of the bone marrow. 5) Tachycardia, not bradycardia, is seen due to the anemia.