CAT3DB

The nurse provides care for a client undergoing an exercise stress test. The cardiologist is suddenly called away for an emergency. Which action should the nurse take next? 1. Continue the test, as the client was almost finished.2. Stop the test and reschedule for another day.3. Ask the client to stay until the doctor returns.4. Inform the client that the test is finished.

The correct answer is 2 . You answered 1. 1) The stress test cannot continue without a cardiologist present in case the client experiences an emergency from the exertion of the test. 2) CORRECT - The test would need to be rescheduled because a cardiologist must supervise cardiac stress testing. 3) The results will be altered by having the client restart the testing. 4) The stress test must be fully performed from start to finish to give accurate results.

The nurse provides care to a client who reports "ringing in the ears" and dizziness. Which medication in the client's history will the nurse suspect as causing this client's symptoms? 1. Valsartan.2. Amikacin.3. Spironolactone.4. Cinacalcet hydrochloride.

The correct answer is 2 . You answered 3. 1) Valsartan, an angiotensin antagonist, can cause dizziness. However, it does not affect hearing. 2) CORRECT - Amikacin is an aminoglycoside that can cause ototoxicity. Manifestations of ototoxicity include tinnitus and vertigo. 3) Spironolactone is a potassium-sparing diuretic and does not cause ototoxicity. 4) Cinacalcet hydrochloride, a calcium receptor antagonist, can cause dizziness. However, it does not affect hearing.

The nurse notes that a toddler-age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next? 1. Document the findings in the chart.2. Talk to the nursing supervisor.3. Ask the client what happened.4. Discuss the findings with the health care provider.

The correct answer is 2 . You answered 4. 1) The nurse will document the findings in the chart, but this will not be the next step. 2) CORRECT — The nurse should involve the nursing supervisor if abuse is suspected. Each health care facility has a policy on how to address the suspected abuse. 3) A 2-year-old is not a good historian and may not be able to accurately tell the nurse what happened. 4) The health care provider should be notified if abuse is suspected, but it will not be the next step.

A client develops ventricular tachycardia (VT). Which action does the nurse take next when providing care to this client? 1. Auscultate breath sounds.2. Check pulse for a full minute.3. Establish responsiveness.4. Start cardiac compressions.

The correct answer is 3 . You answered 4. 1) Auscultating breath sounds delays emergency treatment. 2) Checking the pulse for a full minute is not necessary. 3) CORRECT - The priority action is to establish responsiveness. 4) Cardiac compressions are necessary only if the client is pulseless.

The nurse provides teaching for a client who has a medication delivered via the use of a transdermal patch. Which client statement requires the nurse to provide additional teaching? 1. "I will remove the old patch before applying the new patch."2. "I will avoid putting the patch on any sites that have bruises."3. "I will shave the skin area before applying the patch."4. "I will place the patch on areas that are hairless."

The correct answer is 3 . You answered 4. 1) Clients should remove an old patch before applying a new patch to prevent medication overdose. 2) Clients should avoid placing transdermal patches on a bruised area. This may alter the absorption of medication. 3) CORRECT - Do not shave skin before applying topical or transdermal drugs. Shaving may cause skin irritation and change the absorption of the drug. This client statement indicates the need additional teaching. 4) Clients should use hairless sites to apply transdermal patches. The patch will adhere best to an area with no hair.

The nurse teaches a group of students about measures to reduce the risk for medical device-related accidents. Which point does the nurse include in the teaching? (Select all that apply.) 1. Bend electric cords for storage.2. Be alert for wet surfaces near electric cords.3. Handle medical equipment with care.4. Avoid using equipment that is unfamiliar.5. Use two-prong electrical plugs when possible.

The correct answer is 2, 3, 4 . You answered 1, 2, 4, 5. 1) The nurse instructs students to avoid twisting or bending electric cords, which could cause the wires inside the cord to break. 2) CORRECT — The nurse teaches students to be alert for wet surfaces in areas where electric cords or connections are present. 3) CORRECT— The nurse instructs students to handle equipment with care to prevent damaging it. 4) CORRECT — The nurse advises the students to become familiar with equipment before using it. 5) The nurse instructs students to use three-prong electrical plugs when possible because they provide grounding, reducing the risk of electrical shocks.

The nurse provides care for a client who has mild pre-eclampsia. Which evaluation data indicate that the nursing interventions to help control mild pre-eclampsia have been effective? 1. The client's blood pressure is 145/95 mm Hg.2. Edema is noticed around the client's eyes.3. The client's patella reflexes are 2+.4. The client's urine protein is 3+.

The correct answer is 3 . You answered 1. 1) A blood pressure less than 140/90 mm Hg indicates that the pre-eclampsia is controlled. This client's blood pressure is high. 2) Edema around the client's eyes is not present if the mild pre-eclampsia is controlled. 3) CORRECT — A 2+ patellar reflex indicates the pre-eclampsia is controlled. 4) A urine protein less than 2+ indicates the pre-eclampsia is not controlled.

The nurse provides care for a client who reports mid-back discomfort. Which technique does the nurse use to determine if the pain is coming from the kidneys? 1. Auscultation.2. Light palpation.3. Blunt percussion.4. Hooking technique.

The correct answer is 3 . You answered 2. 1) Auscultation is not a technique to assess pain but to hear sounds. 2) It is not possible to identify the kidneys using light palpation. 3) CORRECT — Blunt percussion is used over the costovertebral angle to assess for kidney tenderness. 4) The hooking technique is used to palpate the edges of the liver.

The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request.2. Make the accommodation.3. Advocate for modification of the organization's dress code.4. Review the organization's dress code policy.

The correct answer is 4 . You answered 3. 1) Declining the request should not be done without reviewing the dress code policy. 2) Making the accommodation should not be done without reviewing the dress code policy. 3) The organization's policy should be reviewed prior to advocating for change, because the accommodation may already be included in the policy. 4) CORRECT - Reviewing the dress code policy should take place on a regular basis, from a cultural standpoint, to accommodate the various traditional dress needs of employee groups. In addition, the accommodation for wearing the requested clothing may already be covered in the dress code.

The nurse plans care for an older adult client. Which intervention does the nurse implement to reduce this client's risk for falls? 1. Elevate bed to waist height.2. Ensure socks are worn when ambulating.3. Position commode close to the bed.4. Place a chair and overbed table close to the commode.

The correct answer is 3 . You answered 3. 1) The bed should be in the low position. 2) The client should wear nonskid footwear. 3) CORRECT — A bedside commodes reduces the risk of rushing when needing to go to the bathroom. 4) The path to the bedside commode should be clear and free of obstacles.

The nurse works in a clinic located in a community where the population is primarily Hispanic. Which strategy will the nurse implement to decrease health care disparities for these clients? 1. Educate the clinic staff about Hispanic health practices.2. Procure low-cost medications for clinic clients.3. Update equipment at the clinic.4. Improve public transportation to the clinic.

The correct answer is 1 . You answered 4. 1) CORRECT— Because health care disparities are primarily due to stereotyping, biases, and prejudice of health care providers, these can be decreased through staff education. 2) Procuring low-cost medications for clinic clients may be addressed by the nurse, but will not have a direct impact on health disparities. 3) Updating equipment at the clinic will not have a direct impact on health disparities. 4) Improving public transportation to the clinic will not have a direct impact on health disparities.

The nurse prepares a client for surgery. Which task is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Performing a clean catch urinalysis.2. Collecting vital signs.3. Monitoring lung sounds.4. Applying compression stockings.5. Educating on incentive spirometer use.

The correct answer is 1, 2, 4 . You answered 1, 2, 4. 1) CORRECT — The NAP is able to obtain a clean catch urinalysis. The task is appropriate for a NAP to complete on a client. 2) CORRECT — The NAP is able to obtain vital signs. The task is appropriate for a NAP to complete on a stable client. 3) Monitoring lung sounds would not be an appropriate task to delegate to a NAP. Listening to lung sounds is an assessment, and a NAP should not perform an assessment. 4) CORRECT — The NAP can apply compression stockings. The task is appropriate for a NAP to complete. 5) Educating a client on the use of the incentive spirometer is not an appropriate task to delegate to a NAP. Education needs to be completed by the nurse.

Which action will the nurse take to maintain safety when providing a client with a blood product? (Select all that apply.) 1. Verify client's identification according to institutional policy.2. Administer blood product as soon as it arrives on the care area.3. Transfuse blood products in less than 2 hours for maximum effect.4. Stay with the client during the first 15 minutes of the transfusion.5. Obtain an order for oxygen 2 L via nasal cannula during transfusion.

1) CORRECT - Positive identification of the client is a gold standard when transfusing blood products. 2) CORRECT - Blood products are administered as soon as they arrive on the care area. 3) A unit of whole blood or packed RBCs is ideally transfused in 2 hours. If the client is at risk for developing fluid volume excess, the transfusion time can be extended to 4 hours. There is a risk for bacterial contamination of the blood beyond the 4-hour mark. 4) CORRECT - Staying with client for the first 15 minutes is part of transfusion best practices and provides the nurse with the opportunity to detect a reaction. 5) Oxygen is not routinely administered when providing a blood product.

The parents bring their 4-month-old infant to the clinic for a wellness visit. They report trying to give the infant prepackaged baby food a couple of weeks ago, but the infant stuck out the tongue and would not take the food. Which response by the nurse is appropriate? 1. "That's a natural reflex; it will soon disappear and then your baby will be ready for solid foods."2. "Try introducing another food. Your baby probably doesn't like the taste of what you tried."3. "Keep introducing foods, as it may be the texture of the food you tried."4. "Try pureeing your own food instead of giving the prepackaged baby food."

The correct answer is 1 . You answered 1. 1) CORRECT - The tongue extrusion reflex is a natural reflex for an infant who is not developmentally ready for solid foods. This reflex disappears at about 4 to 6 months when solid food can be safely introduced into the diet. 2) The infant is not developmentally ready for solid foods. Sticking out the tongue does not indicate a distaste for food. 3) The infant is not developmentally ready for solid foods. Sticking out the tongue does not indicate a negative response to texture. 4) The infant is not developmentally ready for solid foods, whether store bought or prepared at home.

The nurse provides care for a client who takes potassium chloride 40 mEq by mouth twice daily. The client's serum creatinine level is 1.9 mg/dL. Which action is the priority for the nurse? 1. Obtain an order for a renal consultation.2. Administer the potassium as prescribed.3. Monitor the client's intake and output.4. Notify the client's health care provider (HCP).

The correct answer is 4 . You answered 4. 1) The serum creatinine level of 1.9 mg/dL is greater than the normal range of 0.6 to 1.2 mg/dL. A renal consult may be needed, but the priority is to notify the HCP. Giving potassium may cause hyperkalemia due to possible impaired kidney function. 2) Giving potassium to a client with elevated serum creatinine may cause hyperkalemia. 3) Monitoring intake and output does not address the priority concern of hyperkalemia if potassium is given to the client with high serum creatinine. 4) CORRECT - An elevated serum creatinine level indicates possible impaired kidney function, which could result in hyperkalemia. The nurse should notify the HCP before administering potassium.

The nurse provides care for a client with a nasogastric (NG) tube attached to wall suction. The nurse notes large amounts of gastric secretions in the suction canister. Which arterial blood gas (ABG) result does the nurse expect to observe? 1. PaCO2 50 mmHg, pH 7.20.2. PaCO2 40 mmHg, pH 7.40.3. HCO3 28 mEq/L (28 mmol/L), pH 7.50.4. HCO3 20 mEq/L (20 mmol/L), pH 7.30.

1) This ABG result is reflective of respiratory acidosis. Normal PaCO2 is 35 to 45 mm Hg. The nurse does not expect to observe this ABG when providing care to this client. 2) The ABG result indicates a normal PaCO2 and pH. The nurse does not expect to observe this ABG when providing care to this client. 3) CORRECT- This ABG result is reflective of metabolic alkalosis. A client experiencing metabolic alkalosis has an elevated HCO3 [normal is 22 to 26 mEq/L (22 to 26 mmol/L)] and a elevated pH (normal is 7.35 to 7.45). Causes of metabolic alkalosis include vomiting, gastric suction with loss of hydrogen and chloride ions, long-term diuretic therapy, significant potassium depletion, cystic fibrosis, chronic ingestion of milk and calcium carbonate, and Cushing syndrome. The nurse anticipates this ABG data when providing care for this client. 4) This ABG result is reflective of metabolic acidosis. The nurse anticipates metabolic alkalosis, not acidosis, when providing care for this client.

The nurse provides care for a client with a serum sodium level of 120 mEq/L. Which nursing action is a priority? 1. Monitor for neurological changes.2. Check the client's serum creatinine level.3. Assess the client's functional status.4. Obtain a prescription for intravenous dextrose 5%.

The correct answer is 1 . You answered 1. 1) CORRECT — Sodium is essential in the transmission of nerve impulses. Severe hyponatremia — normal sodium range 135 to 145 mEq/L — can lead to coma and seizures. Therefore, this is the priority nursing action. 2) While checking the client's serum creatinine level is part of a comprehensive assessment, this is not the priority nursing action. 3) While assessment of functional status is appropriate, this is not the priority nursing action. 4) Hypertonic saline, not dextrose, is indicated in the treatment of severe hyponatremia.

The nurse provides an older client, who was recently widowed, with a list of activities available at a local library. For which nursing diagnosis is this action most appropriate? 1. Risk for loneliness.2. Risk for ineffective coping.3. Risk for complicated grieving.4. Risk for situational low self-esteem.

The correct answer is 1 . You answered 1. 1) CORRECT — The older widowed client has lost a spouse and is at risk for loneliness. Providing a list of activities available at a local library provides opportunities for the client to participate in socialization at the client's convenience. 2) Factors that can increase the risk for ineffective coping include a stressful home environment, inadequate resources, and work overload. A list of library activities would not help with ineffective coping. 3) Although the death of a significant other can precipitate complicated grieving, other factors need to be considered, such as emotional maturity and period of time since the loss. A list of library activities would not help with complicated grieving. 4) The older widowed client is now alone. There is no reason to expect the client to experience low self-esteem after the loss of the spouse. A list of library resources would not help with situational low self-esteem.

The nurse provides home care to a client receiving intravenous therapy and enteral nutrition. Which care objective will the nurse identify as a priority for this client? 1. Screening.2. Counseling.3. Education.4. Case management.

The correct answer is 3 . You answered 1. 1) Screening is preventive care. 2) Counseling is assisting the client and family to identify strategies and resources to improve the client's condition or the care situation. 3) CORRECT — Health promotion and education are the primary objectives of home care, yet at present most clients receive home care because they also need nursing care. 4) Case management is observing and examining the client to determine what the health status is, what the care needs are, and what resources are available to meet those needs.

The nurse provides care to a client requiring a sterile dressing change. Which action will the nurse take when preparing the sterile field? 1. Place sterile items within 2.5 cm (1 in.) of the edge of the sterile field.2. Hold the bottle of sterile solution with the label facing down.3. Wear sterile gloves when opening sterile gauze.4. Reach over the sterile pack to open the edges.

The correct answer is 1 . You answered 1. 1) CORRECT — The outer 2.5 cm (1 in.) of the sterile field is not considered to be sterile. Therefore, the nurse should place all sterile items within 2.5 cm (1 in.) of the edge of the sterile field to ensure all items remain sterile. 2) The nurse should hold the bottle of sterile solution at a slight angle so that the label is facing up, away from the field. That way, if any of the solution drips onto the outside of the bottle, it does not damage the label and make it illegible. 3) Wearing sterile gloves when adding sterile dressings to the field will contaminate the gloves as the outer wrappers are not sterile. Instead, the nurse should open the packages by holding the wrapper in the nondominant hand and peeling the wrapper open to drop the dressing carefully onto the field. 4) The nurse should reach around the sterile pack, pinch the flap with the thumb and index finger, and open the top flap away from the body to prevent contaminating the inside of the package.

The nurse is teaching the parent of a 2-year-old client on how to correctly administer ear drops. Which action by the parent indicates to the nurse a need for further education? 1. Pulls the pinna up and back.2. Directs the drops along the side of the ear canal.3. Removes the ear drops from the fridge 30 minutes before giving.4. Keeps the child lying down for 5 to 10 minutes before administering drops in the other ear.

The correct answer is 1 . You answered 1. 1) CORRECT — The pinna should be pulled down, not up and back. This parental action indicates to the nurse a need for further education. 2) Drops should be directed along the side of the ear canal; therefore, this parental action demonstrates correct understanding of the procedure. 3) Ear drops should be at room temperature; therefore, this parental action demonstrates correct understanding of the procedure. 4) The child should be lying down for 5 to 10 minutes before administering drops in the other ear; therefore, this parental action demonstrates correct understanding of the procedure.

The parents of a young preschool-age client report that their child becomes easily frustrated and acts out. Which suggestion does the nurse offer to help the parents with their child's behavior? 1. "Use positive redirection to guide the child toward a positive action."2. "Ignore the behavior. A 3-year-old child is too young for discipline."3. "Use a 10-minute time-out to allow your child time to cool down."4. "Encourage your child to verbalize feelings to you."

The correct answer is 1 . You answered 1. 1) CORRECT — Verbally guiding the child to positive behavior may be effective for a young preschool-age client. 2) Parents should begin disciplining the child before this stage of devlopment. It is acceptable to selectively ignore situations if the behavior is not a major issue. 3) Time-outs can be used when appropriate but should not exceed 1 minute for each year of age. 4) A young preschool-age client is unable to verbalize feelings and becomes easily frustrated, exhibited by acting out.

A client claims to feel ugly because of hair lost after receiving chemotherapy for breast cancer. Which statement does the nurse make to help the client cope with these feelings? 1. "Let's see how you look with a scarf or hat."2. "Your hair will grow back after your treatments are over."3. "Many women choose to shave their head when this starts to happen."4. "Just think how much easier it will be to not have to do your hair every day."

The correct answer is 1 . You answered 2. 1) CORRECT — The client has feelings of low self-esteem because of the hair loss. The nurse needs to make a statement that will help the client improve these feelings. Suggesting a scarf or hat is appropriate. It offers an immediate solution to a client. 2) The loss of hair impacts body image. Making a statement about something that will occur in the future does not help the client's feelings right now. 3) The client feels ugly because of the hair loss. Shaving the head might exacerbate these feelings. 4) Although the nurse is trying to say something positive about the client's hair loss, saying that the loss of hair reduces work is not supportive nor does it help with the client's body image or low self-esteem.

The nurse provides care for a client experiencing acute anxiety. It is most important for the nurse to assess the client for which acid-base imbalance? 1. Respiratory alkalosis.2. Respiratory acidosis.3. Metabolic alkalosis.4. Metabolic acidosis.

The correct answer is 1 . You answered 2. 1) CORRECT—Anxiety causes hyperventilation, which results in a loss of carbon dioxide. Respiratory alkalosis is caused by decreased carbon dioxide in the blood. 2) Respiratory acidosis is caused by elevated levels of carbon dioxide in the blood. It does not result from anxiety. 3) Metabolic alkalosis is caused by a decrease in acids in the blood. It is not related to anxiety. 4) Metabolic acidosis is caused by an increase in acids in the blood. It is not related to anxiety.

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.

The correct answer is 1 . You answered 3. 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 family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Teach family members about physical signs of impending death.2. Encourage the management of adverse signs and symptoms.3. Assess family coping mechanisms to handle impending loss.4. Avoid spirituality as nurse's beliefs may not be congruent with the client's.5. Leave the family alone as there is no more need for direct nursing care.

The correct answer is 1, 2, 3 . You answered 1, 2, 3. 1) CORRECT — Teaching about physical signs of impending death will help allay the family's fears and anxiety. 2) CORRECT — Managing adverse signs and symptoms allows maximum comfort of the client. 3) CORRECT — Assessing family coping mechanisms allows the provision of client and family-centered care. 4) Spirituality/spiritual practices may bring comfort to the client and family. 5) Abandoning the family is not appropriate. They are a part of end-of-life care.

The nurse assists the health care provider with cardioversion for a client with uncontrolled atrial fibrillation. Which step does the nurse take during cardioversion that is omitted during defibrillation? 1. Ensure the defibrillator is set in the synchronized mode when delivering the charge.2. Use a conduction medium between the paddles and the client's skin if paddles are used.3. Apply 20 to 25 pounds of pressure when using paddles to deliver the charge.4. Record the delivered energy and resulting rhythm.

The correct answer is 1 . You answered 3. 1) CORRECT - When cardioverting, set the defibrillator to synchronized mode so the device recognizes the QRS complex and the charge is discharged at the proper time in the cardiac cycle. 2) A conduction medium is used between the skin and the paddles for both cardioversion and defibrillation to ensure adequate conductivity. 3) Twenty to 25 pounds of pressure to ensure good skin conduction is applied when delivering a shock for either defibrillation or cardioversion. 4) The delivered energy and resulting rhythm is recorded for both defibrillation and cardioversion.

The health care provider prescribes intramuscular pain medication for a child recovering from an appendectomy. Which is the most appropriate action for the nurse to take? 1. Advocate for the child to see if the medication can be given by an alternate route.2. Disinfect the injection site and allow it to dry completely.3. Administer a topical anesthetic at the intended injection site.4. Administer the medication by the intravenous route.

The correct answer is 1 . You answered 3. 1) CORRECT— Following the principles of atraumatic care, the nurse should advocate for the child to determine if the medication can be given by an alternate route. Intramuscular injections should be rare. 2) Preparing the injection site is appropriate only if the route cannot be changed. 3) Applying a topical anesthetic is appropriate only if the route cannot be changed. 4) Administering the medication by the intravenous route is appropriate only if the medication is available in intravenous form and an intravenous access is present.

The nurse provides care to a client diagnosed with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which goal is most appropriate to include in the nursing care plan? 1. Improve gas exchange.2. Perform activities of daily living without dyspnea.3. Obtain flu and pneumonia vaccinations.4. Sleep for 8 hours without interruption.

The correct answer is 1 . You answered 3. 1) CORRECT— Gas exchange is a priority for this client. 2) Performing activities of daily living without dyspnea may be appropriate after gas exchange is improved. 3) Vaccinations would be appropriate after gas exchange is improved. 4) Sleep needs vary. This may not be realistic for this client.

The nurse provides care to a client receiving lactulose as treatment for hepatic encephalopathy. For which reason will the nurse withhold the next scheduled dose of the medication? 1. Experienced five watery stools today.2. Increased confusion. 3. Serum potassium level 4.0 mEq/L (4.0 mmol/L).4. Reported intestinal cramping.

The correct answer is 1 . You answered 4. 1) CORRECT - Two to three soft bowel movements is desireable when taking lactulose. Watery stools indicate lactulose overdose. 2) Lactulose is used to improve mental status. 3) The serum potassium level is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). 4) Intestinal cramping is a side effect, but not an adverse effect.

The nurse provides care to a client receiving intravenous heparin. Which laboratory test result causes the nurse to be most concerned? 1. Platelet count 50 mm3/L (50×109/L).2. Sodium level 130 mEq/L (130 mmol/L).3. Potassium level 3.2 mEq/L (3.2 mmol/L).4. Partial thromboplastin time 70 seconds.

The correct answer is 1 . You answered 4. 1) CORRECT — A platelet count less than 100 mm3/L signals heparin-induced thrombocytopenia, a potentially life-threatening complication of heparin therapy. 2) Although the client's sodium level is abnormally low, hyponatremia is not an adverse effect of heparin therapy. 3) The client's potassium level is abnormally low, but that is not an adverse effect related to heparin therapy. 4) A partial thromboplastin time of 70 seconds is within therapeutic range for heparin therapy.

The nurse is discussing infection control guidelines with a group of student nurses. Which information is most important for the nurse to include in the discussion? 1. "A gown should be worn when measuring the blood pressure of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection."2. "The door should be kept closed to the room of a client with a clostridium difficile (C. diff) infection."3. "Disposable dishes should be provided for a client with a hepatitis B infection."4. "A surgical mask should be worn when providing care for a client with pulmonary tuberculosis."

The correct answer is 1 . You answered 4. 1) CORRECT — Contact precautions are used to minimize the spread of pathogens that are acquired from direct or indirect contact, especially multidrug-resistant organisms such as MRSA. 2) The door does not need to be kept closed to the room of a client with a C. diff infection. Contact precautions are being used. 3) Clients with hepatitis B do not require any transmission-based precautions. 4) Clients with pulmonary tuberculosis require high-efficiency particulate air masks to be worn whenever a nurse enters the room.

The nurse provides care for a client with chronic obstructive pulmonary disease (COPD). The nurse determines that formoterol is effective if which finding is noted on assessment? (Select all that apply.) 1. The client's PaO2 of 88 mm Hg.2. The client is alert and oriented X 4.3. The client experiences a baseline weight loss of 12%.4. The client's arterial PaCO2 of 52 mm Hg.5. The client's pH is 7.33.

The correct answer is 1, 2 . You answered 1, 2, 3. 1) CORRECT - A PaO2 of 88 mm Hg is within normal range of 85 to 95 mm Hg and indicates improved oxygenation. Formoterol is a long-acting bronchodilator. 2) CORRECT—Improvement in cognitive status (alert and oriented to person, place, time, and situation) indicates improved oxygenation. 3) Weight loss is caused by COPD. It is not an effect of formoterol. 4) A diagnosis of COPD results in the high PaCO2 level of 52 mm Hg, which is significantly elevated above normal range of 35 to 45 mm Hg. This is not a therapeutic effect of formoterol. 5) A diagnosis of COPD results in decreased pH below normal range of 7.35 to 7.45, which is indicative of respiratory acidosis due to air-trapping. This is not a therapeutic effect of formoterol.

The nurse provides care for an adolescent client experiencing a migraine headache. Which finding causes the nurse to be most concerned? 1. Blurred vision.2. Nausea and vomiting.3. Sound and light intolerance.4. Urinary incontinence.

The correct answer is 4 . You answered 1. 1) Blurred vision is a typical migraine symptom. 2) Nausea, and even projectile vomiting, are common symptoms of migraines. 3) Sounds, lights, and odors can all be a source of discomfort for the client with a migraine headache. 4) CORRECT — Incontinence of bowel or bladder could signal seizure activity or a stroke, which is an uncommon, but serious, migraine complication.

Which activity appropriately demonstrates the nurse's role as client advocate? (Select all that apply.) 1. Defending client participation in decisions affecting them.2. Protecting clients from incompetent or unethical practice.3. Safeguarding the client's autonomy and independence.4. Telling clients they must take all medications prescribed by health care providers.5. Communicating client needs to the interdisciplinary team.

The correct answer is 1, 2, 3, 5 . You answered 1, 2, 3, 5. 1) CORRECT — An appropriate nurse advocate role is to promote client self-determination. 2) CORRECT — An appropriate nurse advocate role is to promote client safety. 3) CORRECT — An appropriate nurse advocacy role is to promote client rights. 4) Clients have the right to know the actions and side effects of their medications. A client then can refuse to take any or all medications. Telling clients that they must take all their medication violates the ethical principle of veracity. 5) CORRECT — An appropriate nurse advocacy role is to promote coordinated continuity of care for clients.

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.

The correct answer is 1, 2, 4 . You answered 1, 2, 4, 5. 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 overhears an argument between a client and the nursing assistive personnel (NAP). Which action will the nurse take to resolve this conflict? (Select all that apply.) 1. Listen to the NAP's issue.2. Listen to the client's issue.3. Change the NAP's assignment.4. Offer approaches to eliminate the issue.5. Reprimand the NAP for aggressive behavior.

The correct answer is 1, 2, 4 . You answered 1, 2, 4. 1) CORRECT - When resolving conflict, the nurse needs to listen to all individuals' points of view. 2) CORRECT - The nurse needs to hear from the client what is causing the conflict. 3) This might be the final action for the nurse to take if the conflict cannot be resolved between the NAP and the client. 4) CORRECT - Offering approaches to resolve the issue demonstrates collaboration. This is one way to reach an acceptable conclusion. 5) Reprimanding staff may be beyond the nurse's level of responsibility and would not be one of the first steps to take to resolve the conflict.

The nurse provides discharge instructions to an adult client hospitalized for pneumococcal pneumonia. Which instruction does the nurse include in the teaching plan? (Select all that apply.) 1. "Finish all of the antibiotics, even if you start to feel better."2. "Continue doing your breathing exercises and using the spirometer."3. "Report any cough or mucous production to your health care provider."4. "Avoid large crowds because your immune system is weakened."5. "Report any increase in shortness of breath to your health care provider."

The correct answer is 1, 2, 4, 5 . You answered 1, 2, 4, 5. 1) CORRECT — Early discontinuation of antibiotics may result in failure to completely resolve the infection. 2) CORRECT — Continuing active respiratory exercises will aid in decreasing congestion and managing secretions. 3) Cough and mucous production are expected outcomes with resolving pneumonia. 4) CORRECT — Avoiding crowds will lessen the risk of exposure to respiratory infections in a client with a decreased resistance due to recent pneumonia. 5) CORRECT— An increase in dyspnea, fever, chest pain, or chills, or the persistence of a productive cough, may indicate the infection is not resolving as anticipated.

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.

The correct answer is 1, 2, 5 . You answered 1, 2, 4, 5. 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.

Which statement is appropriate for the professional development educator to include in a discussion of medical asepsis with a group of new clinical employees? (Select all that apply.) 1. "It is necessary to keep the door closed when caring for a client on airborne precautions."2. "I need to wear gloves when taking the blood pressure of a client on contact precautions."3. "I should put on a mask when taking the temperature of a client on contact precautions."4. "It is necessary to use disposable dishes and utensils for a client on droplet precautions."5. "A surgical mask is required when working within 3 feet of client on droplet precautions."

The correct answer is 1, 2, 5 . You answered 1, 2, 4, 5. 1) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. It is necessary to keep the door closed when caring for a client on airborne precautions. 2) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. Gloves are required when taking the blood pressure of a client on contact precautions. 3) A mask is not needed when taking the temperature of a client on contact precautions. 4) Disposable dishes and utensils are not needed for a client on droplet precautions. 5) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. A surgical mask is required when working within 3 feet of client on droplet precautions.

The nurse assesses a client's sleep patterns. The nurse suspects that the client has sleep apnea. Which risk factors should the nurse identify as contributing to sleep apnea? (Select all that apply.) 1. Obesity.2. Short neck.3. Hypertension.4. Diabetes.5. Smoking.

The correct answer is 1, 2, 5 . You answered 1, 2, 4. 1) CORRECT - Obesity increases the risk of sleep apnea by increasing airway obstruction when sleeping from excessive tissue around the neck. 2) CORRECT - A short neck increases the risk of sleep apnea by increasing airway obstruction when sleeping from the excessive tissue around the neck. 3) Hypertension is not a risk factor, but can result from untreated sleep apnea. 4) Diabetes is not a risk factor for sleep apnea. 5) CORRECT - Smoking increases the risk of sleep apnea by causing edema in the airway, increasing the risk of airway obstruction.

The nurse provides care to a client diagnosed with a clostridium difficile (C. diff) infection. Which precaution will the nurse take? (Select all that apply.) 1. Wear a protective gown when entering the client's room.2. Put on a particulate respirator mask when administering medications to the client.3. Wear gloves when feeding the client a meal.4. Ask the client's visitors to wear a surgical mask when in the client's room.5. Wear sterile gloves when removing the client's wound dressing.

The correct answer is 1, 3 . You answered 1, 3, 5. 1) CORRECT — The client should be on contact precautions and a gown is needed when coming in direct contact with the client. 2) A particulate respirator mask is needed for clients with tuberculosis. 3) CORRECT — The client should be on contact precautions and gloves are needed when coming in direct contact with the client. 4) A mask is not needed as C. diff requires contact precautions. 5) Clean, not sterile, gloves are needed to remove a dressing.

A nurse prepares to administer medication to a client. Which information should the nurse use as client identifiers? (Select all that apply.) 1. The client's birth date.2. The client's room number.3. The client's provider's name.4. The client's medical record number.5. The client's first and last name.

The correct answer is 1, 4, 5 . You answered 1, 2, 5. 1) CORRECT - The nurse uses two unique client specific identifiers when administering medications. The Joint Commission (TJC) allows the use of the client's birth date as an acceptable identifier. 2) The nurse uses two unique client specific identifiers when administering medications. The Joint Commission (TJC) does not allow the use of the client's room number as an acceptable identifier. 3) The nurse uses two unique client specific identifiers when administering medications. The Joint Commission (TJC) does not allow the use of the client's provider's name as an acceptable identifier. 4) CORRECT - The nurse uses two unique client specific identifiers when administering medications. The Joint Commission (TJC) allows the use of the client's medical record number as an acceptable identifier. 5) CORRECT - The nurse uses two unique client specific identifiers when administering medications. The Joint Commission (TJC) allows the use of the client's first and last name as an acceptable identifier.

The nurse plans a teaching session for a client with iron deficiency anemia. Which teaching point will the nurse include? (Select all that apply.) 1. Take iron supplements 1 hour before or 2 hours after meals.2. Take iron supplements with dairy products.3. Consume foods that are low in fiber.4. Consume beans, leafy green vegetable, and organ meats.5. Continue iron supplements as prescribed, even if no longer feeling fatigued.

The correct answer is 1, 4, 5 . You answered 1, 4, 5. 1) CORRECT - Iron supplements should be taken on an empty stomach, 1 hour before or 2 hours after a meal, because food reduces iron absorption. 2) Dairy products reduce absorption of iron. 3) Consume foods high in fiber to minimize problems with constipation associated with iron supplement use. 4) CORRECT - Foods such as beans, leafy green vegetables, and organ meats are rich in iron. 5) CORRECT - The iron supplement should be taken for as long as it is prescribed.

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.

The correct answer is 2 . You answered 1. 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.

The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client? 1. Gloves.2. Gown and gloves.3. Gown, gloves, and mask.4. Gown and gloves to change the linens; gloves when bathing.

The correct answer is 2 . You answered 2. 1) Although gloves are used for this client, the nurse must also cover clothing with a gown when providing care. 2) CORRECT - The nurse dons a gown and gloves when bathing and changing this client's linens. 3) Nose and mouth do not need to be covered unless droplet or airborne precautions are needed; therefore, a mask is not used in this instance. 4) A gown is worn when providing all care to this client, not only when changing the linens.

The nurse identifies the nursing diagnosis of Stress Urinary Incontinence related to weakened pelvic musculature for a client. Which goal is most appropriate for this client? 1. Engage in a bladder retraining program.2. Reduce the frequency of urinary incontinence episodes through exercises.3. Use adaptive clothing for quick removal.4. Undergo urodynamic testing to assess urine speed and volume.

The correct answer is 2 . You answered 2. 1) Bladder retraining is appropriate for reflex urinary incontinence. 2) CORRECT - The appropriate goal is to reduce stress incontinence episodes. This goal can be accomplished through repetitive exercises to strengthen the muscles of the pelvic floor. 3) Adaptive clothing is appropriate for functional urinary incontinence. 4) Urodynamic testing is appropriate for overflow urinary incontinence.

The nurse provides care for a client in the second trimester of pregnancy. Which finding does the nurse attribute to the normal increase in blood volume during pregnancy? 1. Increase in the respiratory rate.2. Elevation in heart rate of 15 beats per minute (bpm).3. Increase in blood pressure of 20 points.4. Decrease in mean arterial pressure (MAP).

The correct answer is 2 . You answered 2. 1) Deeper breaths, not quicker breaths, overcome the expanding uterus and the upward pressure on the diaphragm. 2) CORRECT — Cardiac output increases as more blood is pumped from the heart with each contraction and the pulse increases by 10 to 15 bpm. 3) Blood pressure does not increase with higher blood volume, rather, resistance to blood flow through vessels decreases. 4) A decreased MAP indicates decreased organ perfusion.

The nurse teaches parents about the nutritional needs of their 6-month-old infant. Which statement by a parent indicates a need for further teaching? 1. "Fruit juice should be limited to 2 to 4 ounces per day."2. "I'll make sure I offer more fruit juice than fruit."3. "Fruit juice is not necessary in my baby's diet."4. "I'll avoid offering a no-spill sippy cup to prevent tooth decay."

The correct answer is 2 . You answered 2. 1) Limit juice for infant 6 months or older to 2 to 4 ounces per day. 2) CORRECT — Fruit has more nutritional benefit than fruit juice. 3) Fruit juice can displace important nutrients from breast milk or formula and needs to be limited. 4) A no-spill sippy cup is not recommended because it does not encourage cup drinking. Juice is in constant contact with the teeth and increases the risk for dental decay.

The nurse cares for a client receiving nasogastric tube feedings. Which method will the nurse use when administering the client's medications? 1. Crush the medications and add them to client's tube feeding.2. Flush the nasogastric tube with 15 mL of water between medications.3. Crush the medications and pour them into the nasogastric tube.4. Place crushed medications together and dissolve with water.

The correct answer is 2 . You answered 2. 1) Medications should not be added to a tube feeding. 2) CORRECT - Flushing the nasogastric tube with 15 mL of water between medications reduces nasogastric tube obstruction and reduces the risk of medication incompatibility in the nasogastric tube. 3) The medications should be dissolved in water first to prevent nasogastric tube obstruction. 4) Each medication should be dissolved separately to reduce the risk of tube obstruction and incompatibility of the medications in the nasogastric tube.

The nurse provides care for a pediatric client experiencing an acute episode of croup. It is most important for the nurse to assess the client for which acid-base imbalance? 1. Respiratory alkalosis.2. Respiratory acidosis.3. Metabolic alkalosis.4. Metabolic acidosis.

The correct answer is 2 . You answered 2. 1) Respiratory alkalosis is caused by decreased carbon dioxide in the blood. A pediatric client experiencing an acute episode of croup causes carbon dioxide retention. 2) CORRECT - Respiratory acidosis is caused by increased carbon dioxide in the blood. The pediatric client experiencing an acute episode of croup has narrowed airways, making it difficult to breathe; thereby, this makes it difficult to eliminate carbon dioxide. 3) Metabolic alkalosis is caused by a decrease in acid in the blood. This finding is not related to croup. 4) Metabolic acidosis is caused by an increase in acid in the blood. This finding is not related to croup.

The nurse provides care for a client reporting crushing chest pain. Which electrocardiogram (ECG) changes support the current nursing diagnosis of cardiac tissue injury? 1. ST segment depression of 2 mm or more.2. ST segment elevation of 2 mm or more.3. QRS duration greater than 0.12 seconds.4. PR interval greater than 0.20 seconds.

The correct answer is 2 . You answered 2. 1) ST segment depression of 2 mm or more indicates ischemia. Ischemia is a decrease in blood supply to the heart tissue, whereas myocardial infarction or cardiac tissue injury is the end point of this ischemia, resulting in death of heart tissue. 2) CORRECT — An ST segment elevation of 2 mm or more indicates cardiac tissue injury, otherwise known as a myocardial infarction. 3) A QRS duration greater than 0.12 seconds may signify premature ventricular contractions. 4) A PR interval greater than 0.20 seconds indicates a heart block.

The nurse delegates care of a stable client to nursing assistive personnel (NAP). Which right of delegation is the nurse following? 1. Right supervision.2. Right circumstance.3. Right person.4. Right direction/communication.

The correct answer is 2 . You answered 2. 1) Since the task is not identified, the right supervision cannot be determined. 2) CORRECT - The client should be stable since NAP cannot assess the client. 3) There is not enough information in the scenario to determine if the right person was selected. 4) There is not enough information in the scenario to determine if the right direction/communication was provided.

The nurse notes the client's electrocardiogram (ECG) tracing shows a prolonged PR interval, a wide QRS complex, and tall peaked T waves. Which action does the nurse take next? 1. Palpate the peripheral pulses.2. Check the serum potassium.3. Raise the head of the bed.4. Obtain serum troponin level.

The correct answer is 2 . You answered 2. 1) The client is experiencing changes associated with hyperkalemia. Palpating the peripheral pulses is not an appropriate nursing action at this time. 2) CORRECT — The client is experiencing changes associated with hyperkalemia. The ECG indicates an emergency situation; therefore, the priority action is to check the serum potassium level. 3) The client is exhibiting symptoms associated with hyperkalemia. Raising the head of the bed does not address the dangers of hyperkalemia. 4) This action is not indicated. The client is exhibiting symptoms associated with hyperkalemia, not cardiac muscle injury.

The nurse instructs a client about a low-fat, high-fiber diet. Which food does the client chose that best indicates an understanding of the low-fat, high-fiber diet? 1. Garden salad with hard-boiled eggs and Italian dressing.2. Vegetable stock soup with vegetables served with oat bread.3. Tuna salad sandwich with celery on whole wheat bread.4. Broiled chicken stuffed with chopped apples and walnuts.

The correct answer is 2 . You answered 2. 1) The salad is low-fat and high fiber, but the eggs and dressing are high in fat. 2) CORRECT — The soup is low-fat because it is made with vegetable stock rather than meat stock. The bread, vegetables, and legumes are high-fiber. 3) The mayonnaise in the tuna salad is high-fat, and the bread has some fiber. 4) The nuts are high-fat, even though they are fiber-rich.

The nurse teaches a parent actions for home safety during the second half of infancy. Which parent statement causes the nurse to be most concerned? 1. "I avoid giving my baby carrot sticks."2. "My baby loves to be in the walker."3. "I keep the bathroom door closed."4. "I lay my baby on the back to sleep."

The correct answer is 2 . You answered 3. 1) Carrot sticks and other food that poses a choking risk should be avoided in infants. 2) CORRECT - The American Academy of Pediatrics does not recommend the use of walkers at any age. Infant walkers may tip over and the infant may fall out. They also allow the infant access to items they would not be able to access until they are able to walk, such as a hot stove or items on the edge of the table. 3) The bathroom door should be kept closed and the toilet lid down to prevent accidental drowning in infants. 4) Infants should be placed on their back to sleep to reduce the risk for sudden infant death syndrome.

The nurse admits several clients during the day shift. Which room assignment is most appropriate for the nurse to make? 1. Assign the client who is returning from an appendectomy to a room with a client who had an incision and drainage of a leg wound earlier today.2. Assign the client who is returning from a total knee replacement to a room with a client diagnosed with pancreatitis.3. Assign the client diagnosed with streptococcal pneumonia to a room with a client diagnosed with staphylococcal pneumonia.4. Assign the client diagnosed with gastritis to a room with a client who is neutropenic.

The correct answer is 2 . You answered 4. 1) A postoperative client should not be in a room with the client who has an infection as the postoperative client is at an increased risk for infection. 2) CORRECT — Neither client is infected. Pancreatitis is an inflammatory process of the pancreas and not an infectious disease. 3) Clients who are diagnosed with two different infectious organisms should not be placed in the same room. 4) A client who is neutropenic should be in a private room.

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.

The correct answer is 2 . You answered 4. 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 provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing? 1. Anemia.2. Malnutrition.3. Activity intolerance.4. Peripheral vascular disease.

The correct answer is 2 . You answered 4. 1) Although fatigue is a manifestation of anemia, dry skin and poor wound healing are not. 2) CORRECT - Manifestations of malnutrition include fatigue from a lack of adequate caloric intake, dry skin from a deficiency in protein and vitamins, and poor wound healing from a lack of adequate protein and vitamins needed for skin repair. 3) Activity intolerance is an assessment finding that could indicate another health problem. 4) Poor wound healing can occur in peripheral vascular disease, but fatigue and dry skin are not necessarily associated with this disease process.

The nurse is teaching a client diagnosed with end stage renal disease about hemodialysis. Which statement indicates that teaching has been effective? 1. "I should have a treatment once a week."2. "I might have muscle cramps after a treatment."3. "The treatment could make my blood clot faster."4. "The treatments reduce my risk of getting infections."

The correct answer is 2 . You answered 4. 1) Hemodialysis treatments are typically scheduled every other day or three times a week. 2) CORRECT — Muscle cramping can occur because of the rapid removal of fluid, electrolytes, and body wastes. 3) The anticoagulants within the dialysate prevent clotting and the risk for bleeding. 4) Hemodialysis treatments actually increase the risk of hepatitis and other blood-borne pathogen infections.

The nurse provides care for a client that reports difficulty falling asleep several nights a week. The nurse reviews the client's bedtime pattern. Which client statement requires an intervention by the nurse? 1. "I turn the TV off about an hour before bed and try to read."2. "I will go to bed when I am wide awake and relax in bed."3. "I will drink some herbal tea to help me wind down for the night."4. "I will limit my naps to 20 minutes a day."

The correct answer is 2 . You answered 4. 1) The client will want to decrease stimuli before attempting to go to bed. Reading is a relaxing activity to help promote sleepiness. 2) CORRECT - It is important to not go to bed when wide awake. The client should practice going to bed when sleepy to promote the bed for sleeping. 3) Most herbal teas are relaxing and do not contain caffeine. 4) If a client does nap, it is recommended the nap be 20 minutes or less.

The nurse teaches a class about birth control. Which client statement about the use of a male condom requires follow-up by the nurse? 1. "Condoms are the only birth control method that prevents the spread of sexually transmitted infections."2. "I will put the condom on before I have an erection to collect all sperm.3. "I will leave a space at the tip for the condom to collect the ejaculate."4. "I will hold the condom firmly at the base of the penis and withdraw the penis before the erection ends."

The correct answer is 2 . You answered 4. 1) The condom is the only method of birth control that prevents the spread of sexually transmitted infections. 2) CORRECT - The condom should be rolled onto an erect penis. 3) A space should be left at the tip of the condom to collect semen. 4) After ejaculating, the rim of the condom should be held while pulling the penis out of the partner's body.

The nurse performs an assessment on a full-term newborn. Which finding does the nurse report to the health care provider? 1. The client's blood pressure of 70/44 mm Hg.2. The umbilical cord is whitish-gray in color.3. Bowel sounds cannot be auscultated in the abdomen.4. The big toe dorsiflexes when the side of the foot is stroked.

The correct answer is 3 . You answered 1. 1) Normal BP range for full-term newborns is 65 to 95/30 to 60 mm Hg systolic. 2) Normal finding for a newborn's umbilical cord is the whitish gray color. 3) CORRECT - Tinkling bowel sounds in 4 quadrants are present within 1 hour after birth 4) A positive Babinski is normal until 2 years of age. In addition to toe dorsiflexion, the toes will fan out.

The nurse provides care for an adolescent client following a traumatic amputation of the left leg. The client states to the nurse, "My life is over now." Which response by the nurse is best? 1. "Your life is not really that bad."2. "You feel like you have nothing to live for."3. "Once you start physical therapy, you will feel better."4. "Why do you feel that way?"

The correct answer is 2 . You answered 4. 1) The nurse is using the nontherapeutic communication technique of giving false reassurance, which can inhibit the client from expressing feelings and fears. 2) CORRECT — The nurse is using the therapeutic communication technique of reflecting, which helps the client explore feelings and ideas about the client's situation. 3) The nurse is using the nontherapeutic communication technique of giving false reassurance, which minimizes how the client feels at this time. 4) By asking a why question, the nurse is using the nontherapeutic communication technique of probing. This can make the client defensive.

The hospice client receives 10 mg of oral oxycodone every 4 hours around the clock for 1 week. The client has become unable to swallow and exhibits moderate restlessness. Which action does the nurse take? 1. Hold the oxycodone, noting in the client's record the inability to swallow.2. Ask the health care provider (HCP) to prescribe an alternative pain medication.3. Dissolve the oxycodone in water and deliver it as a sublingual dose.4. Discontinue the oxycodone and administer a reversal agent for the overdose.

The correct answer is 2 . You answered 4. 1) Withholding a narcotic after a client receives consistent doses may increase discomfort. This action is inappropriate for the hospice client who is exhibiting signs of discomfort, without an alternative medication for discomfort. 2) CORRECT — The HCP would prescribe an equal analgesic dose of narcotic and a new route of administration. 3) A change in route requires HCP permission, and a sublingual method could cause aspiration due to the client's difficulty in swallowing. 4) The client actively dying needs relief from the suffering of pain. A reversal agent is not appropriate.

The nurse reviews ways to prevent client medication errors with a student nurse. Which response by the student indicates that additional teaching is necessary? (Select all that apply.) 1. " I will prepare medications for each client separately." 2. " I should compare the medication administration record against the drug label at least two times before giving the medication to a client."3. " I should trust the health care provider and not question a medication or dose ordered."4. " I will document all medications as soon as I give them."5. " I should use at least two patient identifiers whenever administering medications."

The correct answer is 2, 3 . You answered 3. 1) Medications should be prepared separately for each client. 2) CORRECT - Medications should be checked a minimum of three times. 3) CORRECT - The nurse should question any medication order if unsure of the dose or medication. 4) All medications should be documented as soon as they are provided to the client. 5) At least two patient identifies should be used when administering medications.

The nurse provides care for a client diagnosed with an acute stroke. Which intervention does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Screen the client for thrombolytic therapy.2. Take vital signs based on stroke protocol.3. Measure and record urinary output.4. Assist with positioning the client as needed.5. Evaluate the client's motor strength every hour.

The correct answer is 2, 3, 4 . You answered 2, 3, 4. 1) Screening for thrombolytic therapy is done by the nurse or health care provider. 2) CORRECT — Monitoring, reporting, and documenting vital signs based on protocol is within the scope of practice of NAPs. 3) CORRECT— Measuring intake and output is within the scope of practice of NAPs. 4) CORRECT — Assisting the nurse in turning and positioning high-risk clients is within the scope of practice of NAPs. 5) Assessment and evaluation of outcomes are done by the nurse.

The nurse provides care for a post-operative client. Which conditions does early ambulation after surgery help prevent? (Select all that apply.) 1. Dehiscence.2. Thromboembolism.3. Atelectasis.4. Paralytic ileus.5. Pressure decubiti.

The correct answer is 2, 3, 4, 5 . You answered 1, 2, 4, 5. 1) There is no evidence that ambulation reduces the risk of wound separation. 2) CORRECT - Ambulation reduces the risk of thromboembolism by increasing venous blood flow. 3) CORRECT - Ambulation reduces the risk of atelectasis by increasing the mobilization and expectoration of mucus. 4) CORRECT - Ambulation reduces the risk of paralytic ileus and promotes peristalsis. 5) CORRECT - Ambulation reduces the risk of pressure decubiti by reducing the time in bed and relieving pressure on bony prominences.

The nurse provides care for a group of clients. Which condition puts the client at risk for metabolic acidosis? (Select all that apply.) 1. Pneumonia.2. Diabetes mellitus.3. Asthma.4. Renal failure.5. Malnourishment.

The correct answer is 2, 4, 5 . You answered 2, 4, 5. 1) Pneumonia is a respiratory problem, not a metabolic problem. 2) CORRECT — Diabetes mellitus leads to metabolic acidosis because of the increasing acids in the body. 3) Asthma is a respiratory problem, not a metabolic one. 4) CORRECT — Renal failure leads to metabolic acidosis because of the increasing acids in the body. 5) CORRECT — Malnourishment leads to metabolic acidosis because of the increasing acids in the body.

The nurse provides care for a client that dies unexpectedly. Which task will the nurse safely delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1. Removal of tubes to perform post mortem care.2. Gather the client's belongings for the family to take home.3. Have the family sign an organ donation form.4. Notify the funeral home.5. Notify the kitchen to not send a meal tray.

The correct answer is 2, 5 . You answered 1, 2, 5. 1) Unexpected deaths may require an autopsy. Direction to remove tubes should not occur until it is known if an autopsy is required. 2) CORRECT - The task of gathering the client's belongings can be delegated to NAP. 3) The nurse should provide and explain any forms and will need to witness the forms. This task cannot be delegated to NAP. 4) The nurse should notify the funeral home. This should not be a task delegated to NAP. 5) CORRECT - NAP can notify the kitchen that the client died and will no longer need a tray.

The nurse observes a student assess an older client with dehydration. Which assessment requires the nurse to intervene? 1. Measures orthostatic blood pressure.2. Reviews serial daily weight readings.3. Checks skin turgor on the hand. 4. Reviews serum sodium values.

The correct answer is 3 . You answered 1. 1) Blood pressure should be assessed for orthostatic changes since this could indicate inadequate fluid volume. 2) Daily weights are used to assess hydration. 3) CORRECT - In the older client, skin turgor is best assessed by pinching the skin over the sternum and not the hand. A loss of skin elasticity on the hands provides an inaccurate assessment. 4) Serum sodium values can provide information about hemoconcentration.

The nurse provides care to a client with a terminal illness and discusses withdrawal of care. The family expresses concerns related to discontinuation of the therapy. Which statement by the nurse is most appropriate? 1. "I understand your concerns. We will give the client enough morphine to promote a painless death."2. "You will need to talk to the lawyer. I am not legally allowed to participate in the withdrawal of life support."3. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a more natural death."4. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

The correct answer is 3 . You answered 2. 1) Purposely giving medications to cause death is active euthanasia. The nurse is not involved in active euthanasia. 2) Nurses do participate in the withdrawal of life support. It is important to address the family's concerns. 3) CORRECT - In addressing the concerns with withdrawal of therapy, therapeutic communication includes validating and normalizing responses. 4) Telling the family not to worry does not validate their feelings, and it sounds dismissive of their concerns.

A client experiences a fever, headache, photophobia, and neck stiffness. Which transmission-based precaution will the nurse implement for this client? 1. Contact.2. Airborne.3. Droplet.4. Standard.

The correct answer is 3 . You answered 2. 1) The client's symptoms suggest Neisseria meningitidis meningitis (N. meningitidis), which is spread by large particle droplets. 2) N. meningitidis is not spread by airborne droplet nuclei. 3) CORRECT — The client's symptoms are consistent with N. meningitidis and droplet precautions should be used. 4) Standard precautions should be used for all clients.

A client with diabetes returns from the post-anesthesia care unit (PACU) after a transurethral resection of the prostate (TURP). Which intervention will the nurse perform first? 1. Perform a bedside bladder scan.2. Collect a specimen for urine culture.3. Check patency of the indwelling urinary catheter.4. Obtain a capillary blood glucose level.

The correct answer is 3 . You answered 3. 1) A bladder scan is not needed for client with a TURP returning from the PACU. 2) A urine culture specimen is not routinely collected on client with a TURP returning from the PACU. 3) CORRECT - The priority is to check the patency of the indwelling urinary catheter during the immediate post-operative period. 4) Checking a capillary blood glucose level is a part of comprehensive post-operative management of client with diabetes. However, this is not the first priority during the immediate post-operative care of a client recovering from a TURP.

The nurse provides for a client who is being evaluated for possible thrombolytic therapy. Which lab value would cause the nurse the most concern? 1. Blood glucose of 160 mg/dL (8.88 mmol/L).2. International normalized ratio (INR) of 1.2.3. Platelets of 90,000/mm3 (90 X 109/L).4. Hemoglobin of 9 g/dL (90 g/L).

The correct answer is 3 . You answered 3. 1) A blood glucose of 160 mg/dL (8.88 mmol/L)is elevated, but it is not a contraindication for thrombolytic therapy. 2) An International normalized ratio (INR) of 1.2 is within normal range and not a contraindication for thrombolytic therapy. 3) CORRECT - A platelet count of 90,000/mm3 (90 X 109/L) is low and part of the exclusion criteria for thrombolytic therapy due to higher risk for bleeding. 4) Hemoglobin of 9.0 g/dL (90 g/L)is low, but is not a contraindication for thrombolytic therapy.

The nurse receives a prescription to start an IV dopamine infusion for a client with hypotension. Which action does the nurse take next? 1. Verify that the client has a "full code" status documented.2. Ensure the client has a gauge 18 peripheral IV line.3. Check to see if the client received volume replacement.4. Attach the client to an oxygen saturation monitor.

The correct answer is 3 . You answered 3. 1) A do-not-resuscitate (DNR) prescription does not preclude treatment, such as a dopamine infusion. 2) Dopamine is best administered via a central line since infiltration leads to tissue sloughing. 3) CORRECT— Adequate fluid volume must be achieved before vasopressors are given because this vasoconstrictor results in further reduction in tissue perfusion without volume. 4) Oxygen therapy is provided as clinically required, but it is not related to the dopamine infusion.

The nurse provides care to an adolescent client with a history of frequent urinary tract infections (UTIs). Upon assessment the nurse learns that the client has symptoms of a UTI , is having difficulty in school, and does not want to be at home alone with the parent's spouse. Which action will the nurse take first? 1. Ask the client to use the bathroom and obtain a urinalysis.2. Discuss the client's concerns with the health care provider.3. Ask the parent to leave the room so the nurse can ask the client assessment questions privately.4. Call the social worker to come and talk to the client.

The correct answer is 3 . You answered 3. 1) A urine specimen can be obtained later. 2) The client's concerns should be discussed with the health care provider; however, this is not the first action the nurse should take in this situation. 3) CORRECT — The nurse should obtain as much information as possible from the client first without the parent present. If the parent stayed in the room, the client may not report abuse. 4) The social worker would be required if abuse is suspected. The client's physical needs must be addressed first.

The nurse teaches the parent of a child diagnosed with celiac disease. Which statement does the nurse identify as an indication that the parent understands the teaching? 1. "I will give my child barley soup for lunch."2. "I will make my child sandwiches on rye bread."3. "I will make my child popcorn as a snack."4. "I will give my child oatmeal for breakfast."

The correct answer is 3 . You answered 3. 1) Clients who have celiac disease need to eat a gluten-free diet. Barley flour contains gluten. 2) Clients who have celiac disease need to eat a gluten-free diet. Rye flour contains gluten. 3) CORRECT - Clients who have celiac disease need to eat a gluten-free diet. The child can eat foods containing corn, flax, soy, and rice. 4) Clients who have celiac disease need to eat a gluten-free diet. Oatmeal does not contain gluten, but is often contaminated with wheat (gluten) during growth and processing. Some people with celiac also exhibit a cross-sensitivity to oats. Before feeding the child oatmeal, the child should be tested to see if there is a cross-sensitivity. Then only certified gluten-free oatmeal should be eaten.

The parent of a 22-month-old toddler plans to begin toilet training the child. Which is the most important factor for the nurse to stress to the mother? 1. Consistency in method.2. Maintain a positive attitude.3. Developmental readiness of the child.4. Avoid comparing the child to peers.

The correct answer is 3 . You answered 3. 1) Consistency in method is important once the process has started. 2) Maintaining a positive attitude is important when the child is ready to begin toilet training. 3) CORRECT - A 22-month child isn't developmentally ready for toilet training. The child and parent will become frustrated. 4) Developmental levels of children are individualized. It isn't helpful to compare the child to peers. It is more important to begin toilet training when the child is developmentally ready.

The nurse learns that a client with heart failure has an ejection fraction of 28%. Which outcome will the nurse identify as being the most appropriate for this client? 1. Decreased episodes of nocturia.2. Increased exercise tolerance.3. Reduced preload and afterload.4. Restored fluid volume.

The correct answer is 3 . You answered 3. 1) Decreased episodes of nocturia is not the most appropriate outcome. There is a need to reduce heart failure exacerbations by reducing preload and afterload. 2) The client with an ejection fraction of 28% is expected to have exercise intolerance due to diminished cardiac output. Increasing exercise tolerance is not realistic. 3) CORRECT - Reducing preload (volume) and afterload (vascular resistance) are the most appropriate outcomes. This will reduce heart failure exacerbation. 4) Restoring fluid volume is not relevant for the client with heart failure because of the risk for fluid overload.

A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure? 1. Ask the emergency services team to sign the informed consent.2. Obtain an emergency court order for the surgical procedure.3. Transport the client to the operating room for surgery.4. Ask the police to identify the client and locate the family.

The correct answer is 3 . You answered 3. 1) Emergency services personnel do not have the authority to provide consent for the client. 2) An emergency court order for surgery occurs when a client waives the right to give informed consent. 3) CORRECT - Informed consent of an adult is generally not needed when an emergency is present, and delaying treatment for the purpose of obtaining consent could result in injury or death of the client. 4) Asking the policy to identify the client and locate the family is not the best option because it may take time and would delay the surgical procedures that the client urgently needs.

The nurse provides care to a client with severe hypothermia. Which assessment will the nurse perform first? 1. Determine presence of shivering. 2. Assess the skin for mottling. 3. Examine cardiac monitor for dysrhythmias.4. Review laboratory values for a low calcium level.

The correct answer is 3 . You answered 3. 1) Hypothermia may cause shivering. However, the most important concern is the risk for ventricular dysrhythmia due to hypothermia. 2) Mottling of the skin might result from hypothermia. However, the most important concern is the risk for ventricular dysrhythmia due to hypothermia. 3) CORRECT - Hypothermia places the client at risk for ventricular dysrhythmia. 4) Hypothermia is not associated with hypocalcemia.

The nurse attends a staff development conference on transfusion reactions. Which statement by the nurse indicates the need for further teaching? 1. "I will keep the intravenous line open with normal saline after I stop the transfusion."2. "I will obtain a urine specimen to determine the presence of hemoglobin."3. "I will discard the blood bag and transfusion set in a waterproof bag."4. "I will notify the blood bank if a client has a transfusion reaction."

The correct answer is 3 . You answered 3. 1) If a transfusion reaction is suspected, STOP the transfusion immediately. The next steps include disconnecting the blood tubing and connecting the normal saline infusion to maintain an open intravenous line. This statement indicates understanding of the teaching. 2) If a transfusion reaction occurs, obtain a urine specimen and send it to the laboratory to determine the presence of hemoglobin as a result of red blood cell hemolysis. This statement indicates understanding of the teaching. 3) CORRECT - The blood bag and tubing need to be sent to the blood bank following a transfusion reaction. This statement indicates a need for further teaching. 4) If a transfusion reaction occurs, the blood bank should be notified. This statement indicates an understanding of the teaching.

The nurse provides care for an unconscious client. The nurse finds a stage 2 pressure injury on the client's elbow. Which statement indicates the best understanding of the client's perception of pain? 1. There will be a behavioral response if pain is perceived.2. The client is not able to perceive pain.3. The area will be treated as a painful lesion, using gentle cleaning and dressing.4. The client will be medicated with an opioid before a dressing change.

The correct answer is 3 . You answered 3. 1) It is not clear whether painful stimuli are perceived in a comatose client. 2) This statement has not been proven or disproven, so it cannot be verified as correct. 3) CORRECT - Since it is not clearly understood where in the brain pain is perceived, pain may be perceived even in a comatose client. Any noxious stimuli should be treated as potentially painful. 4) Opioids are used very cautiously in an unconscious client. If the client gives a behavioral indication that pain is perceived, then an analgesic should be consisted for administration.

The nurse assigns rooms to clients admitted to the unit. The nurse wants to place clients as far away from the nurses' station as possible to promote rest and relaxation. Which client would be most appropriate for the nurse to place away from the nurses' station? 1. 84-year-old client diagnosed with Parkinson disease.2. 73-year-old client diagnosed with congestive heart failure.3. 58-year-old client who had a total abdominal hysterectomy.4. 68-year-old client diagnosed with a cerebellar tumor.

The correct answer is 3 . You answered 3. 1) Parkinson disease and the client's age warrants the client to be closer to the nurse's station due to the mobility issues. This client is at high risk for falls. 2) Clients diagnosed with congestive heart failure need to be assessed more often for fluid balance. These clients should be closer to the nurses station. 3) CORRECT - A client of this age who has had a total abdominal hysterectomy is the most appropriate to be away from the nurses station. 4) A cerebellar tumor leaves a client with high risk for falls due to balance, mobility, and possible confusion from the tumor. This client should be closer to the nurses station.

The nurse notes that a client who follows Judaism has roast beef and whole milk on the dinner tray. Which action will the nurse take first? 1. Ask the nutrition department to replace the roast beef with pork.2. Deliver the food tray to the client.3. Ask the nutrition department for a new tray.4. Replace the whole milk with skim milk.

The correct answer is 3 . You answered 3. 1) Pork and pork products are not allowed by the traditional Jewish religion. 2) The nurse would not do this, because the nurse recalls that combining meat with dairy is not acceptable in the Jewish religion. 3) CORRECT - This is the necessary action to comply with the client's religious preferences. The dairy-meet combination is not acceptable. 4) The fat content of the milk is not an issue in this case.

The nurse screens a client for sleep apnea. Which question is most important for the nurse to ask the client? 1. Do you have difficulty staying asleep?2. What time do you wake up in the morning?3. Has anyone told you that you snore loudly?4. Do you fall asleep at the wrong times?

The correct answer is 3 . You answered 3. 1) Questions about difficulty falling asleep relate to insomnia screening, not sleep apnea. 2) Questions about time of waking up relate to insomnia screening, not sleep apnea. 3) CORRECT - Snoring is associated with obstructive sleep apnea. 4) Questions about sleeping at the wrong times relate to narcolepsy screening, not sleep apnea.

The nurse provides care to victims of a disaster. Which client will the nurse assess first? 1. An 8-month-old client with a laceration over the left eye, a blood pressure of 84/50 mm Hg, and a pulse of 105 beats/min.2. A 6-year-old client with crush injuries to both legs, fixed and dilated pupils, and an absent pulse.3. A 20-year-old client with a traumatic left below the knee amputation, a blood pressure of 70/46 mm Hg, and a pulse of 124 beats/min.4. A 28-year-old client with a hematoma on the forehead, a Glasgow Coma Scale of 11, and is crying.

The correct answer is 3 . You answered 3. 1) The 8-month old client with a laceration is in no acute distress and can be seen later. 2) The client with no pulse is deceased. Post mortem care can be performed later. 3) CORRECT - The vital signs could indicate that the client who has a below the knee amputation could be hemorrhaging. This client should be seen first. 4) The client with a forehead hematoma is in no acute distress and can be seen later.

The supervisor observes the nurse delegate a dressing change on a client with a fever, positive blood cultures, and a blood pressure of 86/42 mm Hg to the LPN/LVN. Which action will the supervisor take next? 1. Encourage the LPN/LVN to complete the dressing change as assigned.2. Assign another LPN/LVN who is more comfortable with dressings to complete the dressing change.3. Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN.4. Ensure that the nurse follows up with the LPN/LVN after the dressing change is complete.

The correct answer is 3 . You answered 3. 1) The LPN/LVN should not complete the dressing change since the client's condition is unstable. 2) Assigning another LPN/LVN to complete the dressing change is not appropriate since the client's condition is unstable. 3) CORRECT - The client is not stable and the nurse should complete the dressing change. 4) The LPN/LVN should not complete the dressing change. Following up with the LPN/LVN would not be appropriate.

The nurse notes that a client requires protective isolation. Which additional client will the nurse safely pair with the client in protective isolation? 1. Client with a urinary tract infection.2. Client with a stage 3 sacral pressure ulcer.3. Client with unstable diabetes mellitus.4. Client recovering from surgery for a perforated bowel.

The correct answer is 3 . You answered 3. 1) The client in protective isolation should not be paired with a client who has any type of infection. 2) It is inappropriate to pair a client at risk for infection with a client who has an open wound and a probable infection. 3) CORRECT — The client with diabetes mellitus is free from infection and can be paired with a client in protective isolation. 4) Recovering from surgery for a perforated bowel exposes the client to infection requiring antibiotic therapy and therefore could expose the client in isolation to infection.

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.

The correct answer is 3 . You answered 3. 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 provides care for a client on bed rest. The nurse determines that the client's right calf is swollen, red, and tender to touch. Which nursing action is most appropriate? 1. Check the client for Homan sign.2. Massage the area.3. Notify the health care provider.4. Teach the client to dangle legs.

The correct answer is 3 . You answered 3. 1) This is not a reliable indicator of thrombus because it can be elicited in any painful condition of calf, not just a deep vein thrombosis (DVT). 2) Massing the area can dislodge a thrombus, causing embolus. 3) CORRECT — The assessment data indicates a possible thrombus; therefore, the priority nursing action is to notify the health care provider. 4) The client is taught to elevate legs to prevent venous stasis, not dangle the legs.

A client with transient confusion coughs constantly while being fed by nursing assistive personnel (NAP). Which action will the nurse take first? 1. Auscultate breath sounds.2. Offer the client sips of water.3. Direct the NAP to stop feeding the client.4. Assess the oral cavity for pocketing of food.

The correct answer is 3 . You answered 4. 1) Breath sounds can be auscultated after the client stops coughing and is comfortable. 2) Thin fluids should be avoided in the client at risk for aspirating. 3) CORRECT — Coughing is a protective mechanism that occurs when food enters the trachea. The first thing to do is to stop feeding the client. 4) Pocketing of food in the oral cavity would not cause coughing.

The nurse notes that a client's laboratory values are blood urea nitrogen (BUN) 55 mg/dL (19.64 mmol/L) and creatinine 3.5 mg/dL (309.4 µmol/L). For which acid-base imbalance will the nurse assess the client? 1. Respiratory acidosis.2. Respiratory alkalosis.3. Metabolic acidosis.4. Metabolic alkalosis.

The correct answer is 3 . You answered 4. 1) In renal failure, the expected acid-base disturbance is metabolic acidosis. 2) Respiratory alkalosis is caused by increased CO2 excretion, such as in hyperventilation. 3) CORRECT - Elevated BUN and creatinine levels indicate possible renal failure. Renal failure leads to accumulation of hydrogen ions leading to metabolic acidosis. 4) Potential causes of metabolic alkalosis includes vomiting and nasogastric suctioning, but not renal failure.

The nurse provides care for a client experiencing status epilepticus. Which action is most appropriate for the nurse to take? 1. Place a tongue blade in the client's mouth.2. Prevent the client from flailing the arms.3. Remove all pillows and raise the bed rails.4. Maintain the client's head in a midline position.

The correct answer is 3 . You answered 4. 1) It is not recommended that anything be placed in the client's mouth. Inserting objects into the client's mouth used to be done to prevent "swallowing the tongue," which is not possible. 2) Holding the client or preventing movement is not recommended as it may cause injury to the client. 3) CORRECT — Removing pillows and raising bed rails will help prevent the client from falling out of the bed, smothering, or sustaining additional injuries. Padding should be in place at the head of the bed and on the side rails to prevent further injury. 4) The client's head should be positioned so that the tongue and secretions can fall forward during seizure activity.

The nurse provides care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding indicates that the treatment has been effective? 1. Serum osmolality is decreased.2. Serum sodium is decreased.3. Urinary output is increased.4. Urine osmolality is increased.

The correct answer is 3 . You answered 4. 1) The serum osmolality increases or returns to normal when treatment is effective. 2) The serum sodium increases or returns to normal when treatment is effective. 3) CORRECT - Urine output increases when treatment is effective. 4) The urine osmolality decreases or returns to normal when treatment is effective.

A client says, "I promise not to touch the intravenous catheter anymore because I don't want to be slapped again." Which action does the nurse take first? 1. Complete a neurological assessment.2. Ask the nursing assistive personnel (NAP) if the client was slapped when providing care.3. Ask the client where the slap occurred and under what conditions.4. Document the client's statement and report it to the nurse manager.

The correct answer is 3 . You answered 4. 1) There is no reason to suspect that the client needs a neurological assessment. 2) The nurse needs to assess if assault and battery occurred and by whom. The nurse manager is responsible for following up with the person identified as performing the assault and battery, which may or may not be the NAP. 3) CORRECT — The nurse needs to assess if assault and battery occurred and by whom. This should be done prior to documenting and reporting the event to the nurse manager. 4) After assessing the client for more information and evidence of physical injury, an occurrence report should be completed and the nurse manager informed.

A client reports having difficulty falling asleep at night. With which statement will the nurse respond to this client? (Select all that apply.) 1. "Exercising immediately before bed will reduce stress."2. "Reading or watching television in bed will help you relax."3. "Eating a heavy meal before bedtime can interfere with sleep."4. "Maintaining a regular sleep/wake schedule promotes sleep."5. "Napping during the day can interfere with sleep at night."

The correct answer is 3, 4, 5 . You answered 3, 4, 5. 1) Exercise should be avoided for at least 2 hours before going to bed. 2) Reading or watching television in bed can interfere with sleep. The bedroom should be used for sleep and intimacy. 3) CORRECT — Eating a heavy meal before bedtime can cause insomnia. 4) CORRECT — The client should maintain a regular sleep/wake schedule. Getting up at the same time each day is an important factor. A sleep diary may help modify poor sleep habits. 5) CORRECT — Daytime napping can interfere with nighttime sleep. If napping is necessary to avoid an accident or injury, limit it to a maximum of 20 to 30 minutes and set a timer.

The nurse provides care for several clients. Which task does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Determine client's pain level.2. Perform walker use training.3. Assist with meal trays.4. Bathe a client with wounds.5. Obtain routine vital signs.

The correct answer is 3, 4, 5 . You answered 3, 4, 5. 1) Steps of the nursing process, such as assessment, should not be delegated to NAPs. 2) Client teaching should not be delegated to NAPs. 3) CORRECT — It is appropriate for NAPs to assist clients with their meal trays. 4) CORRECT — It is appropriate for NAPs to assist clients with bathing after receiving proper instruction and guidance concerning the client's condition and individual needs. 5) CORRECT — The nurse can safely delegate obtaining routine vital signs to NAPs.

While administering a cleansing enema to a client, the nurse notes the client is restless with a rigid and distended abdomen. The nurse recognizes this client is experiencing which type of complication? 1. Small bowel obstruction.2. Vagal response.3. Rectal impaction.4. Bowel perforation.

The correct answer is 4 . You answered 1. 1) An enema will not cause a small bowel obstruction. 2) A vagal response does not cause the abdomen to be rigid and distended. 3) These signs and symptoms are not consistent with rectal impaction. 4) CORRECT— Abdominal distention and rigidity are signs of bowel perforation.

The nurse provides care for a client dying from cervical cancer. The client states that the pain is "excruciating." Which is the best strategy for the nurse to add to the client's plan of care?" 1. Administer increased opioids as needed.2. Dim the lights and perform guided imagery.3. Use distraction such as music and crossword puzzles.4. Obtain a prescription to deliver analgesics on a schedule.

The correct answer is 4 . You answered 1. 1) An order for as needed pain medication will leave the client with gaps in pain management. The gaps will lead to increased pain as one dose wears off before the next dose begins to take effect. 2) Reducing environmental stimuli is a good strategy for minimal pain, pain that is temporary, or pain that is refractory to pharmacological pain management. 3) Distraction is a good strategy for minimal pain, pain that is temporary, or pain that is refractory to pharmacological pain management. 4) CORRECT - Analgesics should be scheduled and administered around the clock to control excruciating pain.

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?

The correct answer is 4 . You answered 1. 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.

A client diagnosed with a terminal disease questions the nurse about the purpose of diagnostic tests. Which action should the nurse take next? 1. Encourage the client to have the testing performed to validate the diagnosis.2. Contact the radiology department to reschedule the diagnostic tests.3. Inform the health care provider that the client is refusing diagnostic tests.4. Ask the health care provider to discuss the diagnostic tests with the client.

The correct answer is 4 . You answered 1. 1) There is no way of knowing if the diagnostic tests are being prescribed to validate the diagnosis or whether they are fulfilling some other purpose. 2) The client has not asked to have the tests rescheduled, so this action is not appropriate. 3) The client has not refused the tests. Rather, the client is asking questions about the purpose of the tests. 4) CORRECT - When advocating for the client, the nurse should contact the health care provider to have the client's questions and concerns about diagnostic tests addressed.

The nurse instructs a client receiving intramuscular cyanocobalamin injections. Which client statement indicates that teaching is effective? 1. "I should limit eating egg yolks and red meat."2. "I should avoid eating organ meats and shellfish."3. "This medication does not interact with any other medications."4. "I should not drink any alcohol while receiving these injections."

The correct answer is 4 . You answered 2. 1) Egg yolks and red meat do not need to be limited because they are good sources of vitamin B12. 2) Organ meat and shellfish do not need to be avoided because they are good sources of vitamin B12. 3) Cyanocobalamin (vitamin B12) interacts with aminosalicylic acid, neomycin, colchicine, and chloramphenicol. 4) CORRECT - Cyanocobalamin interacts with alcohol and prevents the absorption of vitamin B12.

The nurse evaluates a client with eye ptosis and muscle weakness. Which medication will the nurse anticipate being prescribed as a test for this client? 1. Quinidine.2. Phenytoin.3. Procainamide.4. Edrophonium chloride.

The correct answer is 4 . You answered 2. 1) Quinidine can aggravate myasthenia gravis. 2) Phenytoin can aggravate myasthenia gravis. 3) Procainamide can aggravate myasthenia gravis. 4) CORRECT - The client is demonstrating manifestations of myasthenia gravis. Edrophonium chloride is used to test for improved muscle contractility in a client exhibiting manifestations of myasthenia gravis.

The charge nurse supervises the care of several clients. Which situation requires immediate intervention by the charge nurse? 1. A nurse puts on an isolation gown and gloves before entering the room of a client with localized herpes zoster.2. An LPN/LVN gathers all necessary supplies before entering the room of a client needing a sterile dressing change.3. A nurse talks with family about a client's condition after receiving the client's permission.4. A nursing assistive personnel (NAP) changes the linens on a client's bed while the client with Meniere disease ambulates in the hall.

The correct answer is 4 . You answered 4. 1) Applying an isolation gown and gloves before entering the room of a client with localized herpes zoster is appropriate isolation protocol. 2) It is appropriate for the LPN/LVN to gather all supplies before entering the room of a client needing a sterile dressing change. 3) It is appropriate to talk with family after receiving permission to do so from the client. 4) CORRECT - The NAP should walk with the client diagnosed with Meniere disease because dizziness related to the disease could cause a fall and injury.

The nurse observes a student nurse perform closed urinary catheter irrigation on a client with decreased urinary output. Which observation indicates that the student requires additional teaching to perform the procedure correctly? 1. Clamps the urinary drainage tubing below the irrigation port.2. Draws up 50 mL of sterile saline into a syringe.3. Cleanses the irrigation port with alcohol.4. Quickly instills the sterile saline.

The correct answer is 4 . You answered 4. 1) Clamping the urinary drainage tubing below the irrigation port is a correct action. 2) Drawing up 50 mL of sterile saline into a syringe for irrigation is a correct action. 3) Cleaning the irrigation port with alcohol is a correct action. 4) CORRECT - The solution should be instilled slowly to help loosen clots and sediment and to prevent trauma to the bladder wall.

The health care provider prescribes isoniazid for a client with active tuberculosis. Which statement is most important for the nurse to include when teaching the client about the medication? 1. "You should begin to feel better in 2 to 3 days. If you don't, notify your health care provider."2. "You can safely have one to two glasses of wine daily while taking the medication."3. "You should always take the medication with food, even if it upsets your stomach."4. "Vitamin B6 prevents leg tingling and numbness that can occur with isoniazid."

The correct answer is 4 . You answered 4. 1) If treatment is effective, the client should begin feeling better in 2 to 3 weeks. If there is no improvement after 2 to 3 weeks, the client should notify the health care provider. 2) Isoniazid can cause liver damage. Alcoholic beverages should be avoided while taking the medication. 3) Isoniazid should be taken on an empty stomach if possible, 1 hour before or 2 hours after a meal because food delays absorption. It should be taken with a full glass of water. However, if the client experiences gastrointestinal upset, it can be taken with food. 4) CORRECT — The client should be encouraged to take vitamin B6 (pyridoxine) with isoniazid, as prescribed, to prevent the adverse effects of leg numbness and tingling.

The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). Which finding will the nurse find most concerning? 1. Pallor observed on fingers of the right hand.2. Blood pressure reading of 152/90 mm Hg.3. Pain reported as severe in the left knee and ankle.4. Blood urea nitrogen (BUN) level of 40 mg/dL.

The correct answer is 4 . You answered 4. 1) Raynaud phenomenon commonly occurs in SLE. 2) Hypertension is an expected cardiac side effect; pericarditis is the most common cardiac finding. 3) Joint symptoms occur in 90% of clients with SLE. 4) CORRECT — A BUN of 40 mg/dL is well above the normal range of 10 to 20 mg/dL. Nephritis is the most common renal problem; however, the potential for renal disease must be managed aggressively and early to prevent kidney failure.

While changing a client's bed linen, the nurse sustains a needlestick injury from a syringe left in the bed. After washing the injury with soap and water, which action does the nurse take next? 1. Send the needle to the laboratory for testing.2. Interview the client about infection status.3. File an incident report according to protocol.4. Notify the nurse manager as soon as possible.

The correct answer is 4 . You answered 4. 1) Testing the needle is not part of evidence-based practice in handling needlestick injuries. 2) Interviewing the client is not a priority action in needlestick injuries. 3) Although an incident report needs to be done, it is not the priority action. 4) CORRECT -The injured nurse must notify the nurse manager as soon as possible to ensure that proper protocol is observed and the nurse's safety is assured.

The nurse makes assignments for the health care team consisting of three nurses and one LPN/LVN. Which client will the nurse assign to the LPN/ LVN? 1. Client admitted 4 days ago with pulmonary fibrosis. Client is on a venturi mask with 40% oxygen concentration and flow rate at 15 L/min.2. Client admitted yesterday with lower gastrointestinal bleeding. Client reports lightheadedness and dizziness.3. Client admitted today with episodic chest discomfort. Initial troponin T level is > 0.1 ng/mL.4. Client admitted 3 days ago with upper gastrointestinal bleeding. Yellowish green drainage noted in nasogastric suction container.

The correct answer is 4 . You answered 4. 1) The client with pulmonary fibrosis requires frequent assessment of breathing. The nurse should care for this client. 2) The client with lower gastrointestinal bleeding is symptomatic due to fluid volume loss, and is potentially unstable. The nurse should care for this client. 3) The troponin T level of the client with chest discomfort is elevated (normal is < 0.1 ng/mL). An elevation indicates a myocardial injury. The nurse should care for this client. 4) CORRECT - The client with upper gastrointestinal bleeding is stable. The lack of coffee-ground or bright red blood in the nasogastric tube suction indicates that the client is no longer bleeding. The LPN/LVN can care for this client.

The nurse provides care for four clients. Which client will benefit the most from a multidisciplinary conference? 1. A 3-month-old client with intussusception who is vomiting, has colicky abdominal pain, and is having jelly-like stools.2. A 2-month-old client with respiratory syncytial virus (RSV), who is wheezing and has moderate subcostal retractions and copious nasal discharge.3. A 3-day-old client with developmental dysplasia of the hip, who has unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds.4. A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant.

The correct answer is 4 . You answered 4. 1) The infant has signs that are characteristic of intussusception. There is no need for a multidisciplinary conference. 2) This infant has signs that are characteristic of RSV. There is no need for a multidisciplinary conference. 3) This infant has signs that are characteristic of developmental dysplasia of the hip. There is no need for a multidisciplinary conference. 4) CORRECT - This newborn is experiencing neonatal withdrawal from prenatal exposure to drugs while in utero. Since these drugs crossed the placenta, the infant suffers from withdrawal symptoms after birth and may experience long-term developmental and neurological deficits. Also, this newborn is at risk for abuse from the mother, as these infants are very difficult to console. A multidisciplinary conference including a social worker, a home health nurse, a nutritionist, and a mental health counselor could greatly benefit both the mother and newborn.

The nurse delegates care of a client at risk for venous thromboembolism to the LPN/LVN. Which action by the LPN/LVN causes the nurse to intervene? (Select all that apply.) 1. Reinforce the need to flex and extend legs and feet every 2 hours with the client.2. Apply sequential compression devices to the client.3. Administer enoxaparin 80 mg subcutaneously to the client. 4. Teach the client the symptoms of pulmonary embolism.5. Administer oral norgestimate-ethinyl estradiol to the client.

The correct answer is 4, 5 . You answered 1, 2, 4. 1) It is within the LPN/LVN's scope of practice to reinforce teaching. 2) It is within the LPN/LVN's scope of practice to apply sequential compression devices. 3) Subcutaneous medication administration is within the LPN/LVN's scope of practice. 4) CORRECT - The nurse should perform initial teaching regarding symptoms of a pulmonary embolism. 5) CORRECT - Although medication administration is within the LPN/LVN's scope of practice, the nurse should intervene because this medication increases the risk of venous thromboembolism.