Comprehensive Final ATI
A nurse is providing discharge teaching for a client who has a new prescription for metoprolol. Which of the following instructions should the nurse include? (select all that apply.) 1. "Do not stop taking this medication abruptly." 2. "Count your radial pulse daily." 3. "Change positions slowly." 4. Take the medication right before bedtime 5. Avoid exposure to sunlight
1. "Do not stop taking this medication abruptly." 2. "Count your radial pulse daily." 3. "Change positions slowly." [Clients who stop taking metoprolol abruptly increase their risk for angina, HTN, and MI. They should reduce the dosage gradually over 1-2 weeks.]
A nurse is providing teaching to a client who has a new prescription for doxycycline. The nurse should instruct the client to monitor for which of the following adverse effects?
Photosensitivity
A nurse in an acute care facility is implementing the facility's disaster plan following a flood in the community. Which of the following actions should the nurse take? Turn clients' televisions on so they can learn about the disaster. Identify stable clients in the ICU to transfer to the medical-surgical units. Ask family members to come to the hospital to provide support to clients. Make announcements of the status of the disaster on the public address system.
Identify stable clients in the ICU to transfer to the medical-surgical units. The nurse should identify clients to transfer to medical-surgical units to increase the availability of ICU beds for clients from the external disaster who are critically ill.
A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? Lateral Lithotomoy Trendelenburg Prone
Lateral. A lateral, or side-lying position, promotes uteroplacental blood flow and thus helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness.
A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?
Meperidine. Opioids are more effective for residual limb pain rather than phantom limb pain. Additionally, meperidine is not recommended for chronic pain because using it long-term can cause accumulation of a toxic metabolite.
A nurse is assessing a client who is taking varenicline for smoking cessation. Which of the following findings is nurse's priority? Mood Changes Altered sense of taste Nausea Skin rash
Mood changes The greatest risk to the client is the development of neuropsychiatric effects that can progress to depression and suicide. Therefore, the highest priority finding is a change in the client's mood
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? Offering the client a diet high in fluid and fiber Encouraging active range of motion of the affected leg Removing the weights prior to repositioning the client Inspecting pin sites every 24 hr for drainage
Offering the client a diet high in fluid and fiber A client who is immobile is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function. D) The nurse should plan to inspect the client's pin sites at least every 8 to 12 hr due to the risk for infection.
A nurse is teaching the parent of a child who has severe reactive airway disease about glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it orally. Which of the following information should the nurse provide the parent? Inhaled glucocorticoids are less likely to cause thrush. Oral glucocorticoids are hazardous during times of stress. Oral glucocorticoids are more likely to slow linear growth in children. Inhaled glucocorticoids are more effective for acute bronchospasm
Oral glucocorticoids are more likely to slow linear growth in children. Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (the client's airways) resulting in an decreased risk for adrenal suppression.
A nurse at a LTC facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's LOC? Encourage the client to make choices about meals and activities. Use written signs to label specific rooms. Post a large calendar on the bulletin board. Place a wander alert electronic alarm bracelet on the client's wrist.
Post a large calendar on the bulletin board. Posting a large calendar in a central location will assist this client with orientation.
A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? Elevate the client's feet and legs Administer epinephrine. Infuse 0.9% sodium chloride. Stop the medication infusion.
Stop the medication infusion. The greatest risk to the client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen. A) he client is at risk for anaphylactic shock, and the elevation of the client's lower extremities helps to maintain an adequate blood pressure; however, there is another action that the nurse should take first. B) The client is at risk for progression of allergic manifestations and because of the potential progression to anaphylaxis, the provider might prescribe epinephrine; however, there is another action that the nurse should take first. C) The client is at risk for progression to anaphylaxis and infusing isotonic IV fluids can help hydrate the client and maintain blood pressure; however, there is another action that the nurse should take first.
A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication?
Temperature [Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.]
A nurse is assessing a client who is in the fourth stage of labor and suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention? The fundus is at midline. The fundus is below the umbilicus The bladder is resonant with percussion The bladder fluctuates with palpation.
The bladder fluctuates with palpation. With bladder distention, the bladder is suprapubic, round, bulging, is dull to percussion, and fluctuates, as a balloon filled with water would. The uterus is usually displaced to the right, is boggy, and is well above the umbilicus. With bladder distention... A) the uterus is displaced to the right B) the uterus is above the umbilicus C) the bladder sounds dull with percussion
Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18-month-old infant who has Pneumocystis carinii pneumonia indicate that she is HIV-positive. When planning care, the nurse should consider which of the following factors? The infant's mother is likely HIV positive. The infant's ELISA test result is probably a false positive for HIV. Antiretroviral medications are inappropriate for infants and children who have HIV. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.
The infant's mother is likely HIV positive. r- transfer can occur during pregnancy, delivery or breastfeeding. another possiblity is sexual abuse but mother to infant is the majority of the time
A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed RBCs. Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? Warm the unit of blood to room temperature before administering it. Administer acetaminophen prior to the blood transfusion Give an antihistamine prior to the transfusion. Use a transfusion pump to regulate and maintain the transfusion at a slower rate.
Use a transfusion pump to regulate and maintain the transfusion at a slower rate. These are the manifestations of a hypervolemic reaction due to circulatory overload, likely if the blood transfusion is too rapid for the client's size or status. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion at a slower rate. A) This intervention helps prevent chills and hypothermia; however, the client's manifestations are not related to the temperature of the blood. B) This medication can prevent a febrile reaction; however, the client's manifestations do not indicate a febrile reaction. C) If a client is allergy-prone, an antihistamine prior to the blood transfusion can help prevent a reaction; however, the client's manifestations do not indicate an allergic transfusion reaction.
A female client who has recurrent cystitis asks the nurse bout preventing future episodes. For which of the following statements should the nurse provide further teaching?
"I prefer tub baths over showering." Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women who are at risk for UTIs should avoid tub baths because they increase the risk for infection. The nurse should teach the client to take showers instead of tub baths.
A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statements should indicate that the client needs further instructions? "I'll keep an antibacterial hand gel in my purse." "I'm planning a large gathering of friends and family for the holidays." "My partner will have to take care of the cat's litter boxes for a while." "I will eat canned fruits and vegetables."
"I'm planning a large gathering of friends and family for the holidays." A client who has neutropenia should avoid exposure to infection, so this is a statement that warrants more teaching. A client who has neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection.
A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG) in the morning. Which of the following information should the nurse provide the client? "You'll feel some mild electrical sensations, like static electricity, during the procedure." "Do not eat or drink anything except water after midnight." "Shampoo your hair before the procedure, and don't put any styling products on it afterward." "It's common to have a temporary short-term memory loss after the procedure."
"Shampoo your hair before the procedure, and don't put any styling products on it afterward." An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges the nerve cells in the brain release. So that the electrodes will adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products. B) The client should not fast for an EEG because hyopglycemia can affect diagnostic results; however, she should not drink any beverages that contain caffeine the day of the test.
A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation? "Do you like school?" "Tell me about your favorite video game." "We have another child your age on the unit." "Would you like your friends to come and visit you?
"Tell me about your favorite video game." The nurse should use the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication.
A nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include? "The doctor will replace the tubes routinely about every 2 years." "Getting water in her ears will not cause any further problems." "The tubes should stay in place until they fall out on their own." "Now that the tubes are in place, she should not have any further problems with hearing."
"The tubes should stay in place until they fall out on their own." Tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own 6 to 12 months after insertion.
A nurse at a long-term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements should indicate that the AP requires further teaching? "We will be serving breakfast in 10 minutes. I will stay here while you get ready." "It's Monday morning. I know that your favorite television shows are on this evening." "I see that you have a new photo on the wall. Can you tell me who that girl is?" "YIt's almost time for your appointment. Let me do your hair for you and brush your teeth."
"YIt's almost time for your appointment. Let me do your hair for you and brush your teeth." When a client who has dementia has periods of confusion, the AP should allow the client additional time to complete activities that she is able to perform independently. Insisting on completing the task for her, or attempting to hurry her,, can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or truly needs it.
A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) 1. Sit with your back supported 2. Keep your knees at hip level 3. Use ergonomically designed computer keyboard 4. Keep your elbows away from your body 5. Adjust the monitor screen so that you have to tilt your head slightly to look at it
1. Sit with your back supported 2. Keep your knees at hip level 3. Use ergonomically designed computer keyboard
A nurse is observing a client who has schizophrenia and is in the dayroom when another client asks him if two items of clothing match. He replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations? Clang association Echolalia Word salad Associative looseness
Associative looseness A pattern of disordered speech that reflects haphazard and illogical thoughts that lead from one to another. A) Clang association --> sound rather than the meaning of words drives the client's speech pattern, such as rhyming. B) Echolalia --> client continues to repeat the word or statements of another individual. C) Word salad --> client uses real individual words to construct incoherent sentences without meaning.
A nurse is admitting a child who has a UTI and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? Attach a latex allergy alert identification band. Initiate contact precautions. Post signs in the client's bathroom to strain the client's urine. Administer folic acid with meals.
Attach a latex allergy alert identification band. Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.
A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The nurse notes that her left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first? Obtain an x-ray of the injured leg. Apply ice packs to the affected area. Check neurovascular status distal to the injury. Elevate the affected leg on two pillows.
Check neurovascular status distal to the injury. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to this client is impaired circulation to the limb from trauma and the resulting edema; therefore, the first action is to check the circulation, sensation, and movement distal to the level of the injury. If the nurse notes a weak or absent pulse distal to the injury, the limb's circulation is compromised, and immediate action is critical.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant? Don a gown before entering the room and remove it before exiting. Wear a mask while in the client's room. Don gloves when entering the room and use hand sanitizer when exiting Take no special precautions unless you have direct contact with the client.
Don gloves when entering the room and use hand sanitizer when exiting .r- mrsa is contact precautions Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require that any staff who will have contact with the client's environment don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client, and a mask and goggles if secretions from the infected area could spray into the worker's face. Delivering the tray would require contact with the environment; therefore, the dietary assistant must wear gloves.
A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? Warm the feeding in a microwave oven. Elevate the HOB. Flush the tube with 0.9% sodium chloride for irrigation. Verify that the gastric pH is above 4.
Elevate the HOB. Clients following brain injury usually cant swallow easily thus cannot protect their airway from aspiration so raise the hob A) Although a cold enteral formula could cause cramping, it is not necessary to warm the feeding prior to administration. The formula should be at room temperature to improve tolerance of gastrostomy feedings. Also, warming in a microwave oven can cause uneven heat distribution and excessive heat; therefore, it is not a safe way to warm enteral feedings. C) The nurse should flush the tube with water prior to initiating the feeding to ensure patency of the tube. D) Due to the acidity of gastric secretions, the pH of gastric contents should be below 4 to indicate proper placement of the gastrostomy tube. A pH above 4 suggests that the end of the tube is not in the stomach.
A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? Show the client how to use the patient-controlled analgesia pump. Record urinary output after emptying the indwelling urinary catheter. Assist the client out of bed and to the chair for the first time after surgery. Check the client's abdominal wound dressing.
Emptying an indwelling urinary catheter and recording I&O is within the scope of practice for an AP. This task is routine and has a predictable outcome; therefore, the nurse may delegate this task to an AP. C) Assisting a client up out of bed for the first time after surgery is not within the scope of practice of an AP. The client must be medically stable for the nurse to delegate this to an AP.
A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)? Elevated BUN Bradycardia Headache Temperature of 39.2° C (102.5° F)
Headache DDS - A CNS disorder - A complication that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood's pH. Clients beginning hemodialysis are at the greatest risk, particularly if their BUN is above 175. - Causes HA, N/V, decreased LOC, seizures, & restlessness. - Severe S/S: confusion, seizures, coma, & death. A) Increases the risk for developing DDS but not a manifestation B) A loss of body fluid activates the body's compensatory mechanisms. In this case, the rapid decrease in fluid volume after dialysis causes the heart to try to compensate for that volume decrease by increasing the heart rate. Therefore, the client would have TACHYCARDIA, not bradycardia. D) An elevated temperature indicates a possible infection, a common risk for clients undergoing dialysis, not DDS.
A nurse in the emergency department is caring for a client who has Addison's disease and reports N/V, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse should prepare to administer which of the following medications? Calcium Potassium Iodine Hydrocortisone
Hydrocortisone Addison's disease causes adrenal gland HYPOFUNCTION & inadequate production of glucocorticoids. Acute adrenal insufficiency - Life-threatening - Severe fluid and electrolyte imbalances. - W/O tx: Na levels fall & Ka levels increase To correct glucocorticoid deficiency - Rapid infusion of IV fluids (0.9% sodium chloride) - IV admin high dose corticosteroids (hydrocortisone) A) IV calcium corrects hypoparathyroidism B) Acute adrenal insufficiency causes HYPERKALEMIA, for which the client requires a potassium binding and excreting resin, not additional potassium. C) Iodine-containing agents treat thyrotoxicosis
A nurse is assessing a client who has multidrug-resistant TB and takes ethambutol. The nurse should identify which of the following findings as an adverse effect of this medication? Mottling of the extremities Orange-red urine and bodily secretions Yellowing of the sclera Loss of red/green color discrimination
Loss of red/green color discrimination Ethambutol is an antitubercular medication that impairs ribonucleic acid synthesis. Common ADR: loss of red/green color discrimination due to optic neuritis. The nurse should notify the MD of this finding and expect a Rx to discontinue the medication. A) Ethambutol is associated with peripheral neuropathy B) A common adverse effect of another antitubercular medication, rifampin, is that it changes the color of bodily secretions to red-orange.
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? Measure the client's weight daily. Check for tears Palpate the fontanel Assess skin turgor
Measure the client's weight daily. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical for infants and children because fluid accounts for a greater portion of body weight.
A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority? Paresthesia Alopecia Stomatitis Constipation
Paresthesia. [The greatest risk to this client is neurotoxicity. Vincristine, a cell-cycle specific chemotherapy agent, interrupts cellular reproduction at mitosis. One of its adverse effects is neurotoxicity. An early finding with neurotoxicity is paresthesia, or numbing, of the peripheral extremities. As the neurotoxicity progresses, the client can develop autonomic and central nervous system dysfunction. The nurse should report paresthesia immediately, as the provider might change the dosage or the therapy.]
A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia? Patch the unaffected eye. Administer mydriatic eye drops daily. Obtain prescription eyeglasses. Administer antihistamines.
Patch the unaffected eye. Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem, such as strabismus. With strabismus, muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong one. This will result in central blindness if the child does not receive treatment by 6 years of age. To strengthen the weak eye muscles, the parents should patch the unaffected eye.
A nurse is teaching a client who has chronic kidney disease about predialysis dietary recommendations. The nurse should include information about restricting his intake of which of the following nutrients? Protein Carbohydrates Calcium Monounsaturated fats
Protein Dietary restrictions for clients who have chronic kidney disease vary with the degree of kidney function; however, most clients need protein limitations. Predialysis, protein restriction can help preserve some kidney function. B) Clients who have CKD require enough calories to avoid the use of muscle protein for energy. Carbohydrates are a good source of calories for these clients. C) Many clients who have CKDrequire calcium, vitamin D, and iron supplements. D) Clients who have CKD require enough calories to avoid the use of muscle protein for energy. Foods like canola oil and olive oil are monounsaturated fats that can supply additional calories to the client's meals.
A nurse is providing teaching to the parents of a child who has a new prescription of lamotrigine for a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider? Diplopia Dizziness Rash Headache
Rash The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to this client is injury from Stevens-Johnson syndrome or toxic epidermal necrolysis, which are life-threatening reactions that manifest initially as a rash in the first 2 to 8 weeks of treatment with lamotrigine. The nurse should instruct the parents to report a rash immediately to the provider.
A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? Finding the bathroom in the dark Driving at night Seeing numbers on highway signs Reading the newspaper
Reading the newspaper With presbyopia, the lens is unable to change shape to focus on objects close up. - Develops with aging, beginning in middle age, - Results from the decreased elasticity of the lens. A) most likely due to other changes in the vitreous or cornea. B) Usually due to glare from oncoming car headlights. This is most likely due to astigmatism or other changes in the shape of the cornea. C) Most likely due to myopia, or nearsightedness, in which the cornea curves sharply and the focal point is in front of the retina. Objects in the distance are blurry, but those close up are clear.
A nurse is providing discharge teaching to a client who has had a TIA. Which of the following instructions should the nurse include? Reduce dietary sodium. Decrease dietary potassium. Restrict intake of insoluble fiber. Limit alcohol intake to three or fewer servings per day.
Reduce dietary sodium. A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs.
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings should indicate to the nurse that the AAA is expanding? Increased BP and decreased pulse rate Jugular-vein distention and peripheral edema Report of sudden, severe back pain Report of retrosternal chest pain radiating to the left arm
Report of sudden, severe back pain An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities, that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots. B) Manifestations of HF D) Manifestation of MI
A nurse is assessing a client who reports an acute visual disturbance and describes it as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? Cataracts Angle-closure glaucoma Retinal detachment Macular degeneration
Retinal detachment. The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field. A) Cataract - A clouding that develops in the lens of the eye over time. - Slowly impair vision and, without treatment, lead to blindness. S/S: Decreased color perception, blurry vision. B) Angle-closure (acute) glaucoma - Results from a sudden shift in the position of the iris of the eye that blocks the outflow of aqueous humor. - Leads to an acute onset of a severely painful rise in intraocular pressure. - An EMERGENCY S/S: Sudden onset of severe pain around the eyes and face, reduced vision, colored halos, and headaches. D) Macular degeneration - Results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. S/S: Gradual, mild to moderate reduction of central vision.
A nurse manager notes that several staff members are late in completing an annual mandatory educational session about extremity restraint safety. Which of the following actions should the nurse manager plan to take? Make a general announcement at the next staff meeting asking all employees to check their adherence to the requirement. Post a list in the employees' break room naming those who are nonadherent and the date by which they must complete the requirement. Schedule a disciplinary conference with each of the nonadherent employees. Send an e-mail to each nonadherent employee that includes a link to upcoming educational sessions.
Send an e-mail to each nonadherent employee that includes a link to upcoming educational sessions. E-mail provides a simple yet efficient way for the nurse manager to inform nonadherent employees about options they have for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates adherence by helping each employee identify an upcoming session that coordinates with his work schedule.
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? Stop the teaching and check with the surgeon about informed consent.
Stop the teaching and check with the surgeon about informed consent. The client's statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon.
A nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? Sudden HTN Low body temp Sudden oliguria Decreased respirations
Sudden oliguria This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This type of reaction results from the client's antibodies reacting to the transfused RBCs. Indications of intravascular hemolytic reaction. A) Hypotension B) Fever C) Tachypnea (compensatory mechanism)
A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 mm induration with slight redness. Which of the following conclusions should the nurse make? The client has active tuberculosis. The client has had an exposure to tuberculosis. The nurse must re-evaluate the result in 24 hr. The test is negative for tuberculosis.
The client has had an exposure to tuberculosis. A Mantoux test is a skin test that determines exposure to tuberculosis. The nurse should look at the test site and palpate the area to determine if the injection site is raised and feels hard to the touch (induration) and record the results in millimeters to represent the size of the raised bump. Redness alone does not determine a positive result.
A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) with mild manifestations. The nurse should expect that the provider will prescribe which of the following medications? Chlorpropamide Tolvaptan Vasopressin Desmopressin
Tolvaptan SIADH - Disorder of water intoxication due to the inappropriate, continuous secretion of antidiuretic hormone by the posterior pituitary gland - Causes hypervolemia & hyponatremia. Treatment of SIADH - Fluid restriction - Sodium replacement with small amounts of 0.9% sodium chloride - Vasopressin antagonist (tolvaptan) Tolvaptan promotes the excretion of water, which helps to correct the fluid imbalance in clients who have SIADH. Chlorpropamide - Antidiabetic agent - Has antidiuretic effects that would worsen the manifestations of SIADH -Used to treat diabetes insipidus (DI) Vasopressin - Exogenous form of ADH (would worsen SIADH) - Used to treat diabetes insipidus (DI) Desmopressin - Synthetic form of ADH (would worsen SIADH) - Used to treat diabetes insipidus (DI)
A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? "Does your child wear a hat outdoors in cold weather?" "Does anyone smoke around or in the same house as your child?" "Have you given your child any aspirin recently?" "Is your child's diet high in gluten?"
"Does anyone smoke around or in the same house as your child?" [Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space. It also prolongs the inflammation and impedes drainage from the ear.]
A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? "I'll drink less water so I don't have to catheterize myself too often." "I must use sterile technique to do each of the catheterizations." "I should stop the catheterization when I have removed 150 mL of urine." "I will perform intermittent self-catheterization every 2-3 hours."
"I will perform intermittent self-catheterization every 2-3 hours." The client might initially require self-catheterization every 2 to 3 hr, with the frequency eventually increasing to every 4 to 6 hr. A longer interval can result in bladder distention and increased risk for urinary tract infection.
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A) A small, plastic doll with clothes and accessories B) Alphabet flashcards C) A handheld video game D) A 10-piece wooden puzzle
A 10-piece wooden puzzle Age-appropriate toys for a toddler - Puzzles - Large crayons - Blocks - Picture books - Push-pull toys - Finger paints, modeling clay, and musical toys. All allow for manipulation, exploration, and meet the child's developmental & diversional activity needs. A) Preschooler or school age B) Preschooler C) Preschooler or school age
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse? Excessive airway secretions A leak within the ventilator's circuitry Decreased lung compliance The client coughing or attempting to talk
A leak within the ventilator's circuitry [The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.] A) Excessive airway secretions could generate a high-pressure alarm C) Resistance during delivery of a specific volume of oxygen to the client triggers the ventilator's high-pressure alarm, not a low-pressure alarm. A possible cause is decreased lung compliance due to disorders such as COPD. D) When a client is coughing or trying to talk, the ventilator must exert greater force to deliver the preset volume of oxygen. This increase in resistance of the airway against the machine can trigger a high-pressure alarm, not a low-pressure alarm..
A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? Offer the client a nutritious snack. Accompany the client back to his room. Reorient the client to his surroundings. Administer a PRN antianxiety medication.
Accompany the client back to his room. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect him from injury due to wandering.
A nurse is preparing an older adult client who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home? Blood glucose Blood pressure Daily weight Sensation in the feet
Blood pressure A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of another TIA or cerebrovascular accident. A) Blood glucose - for DM D) This is a recommendation for clients who have actual or potential circulatory impairments from disorders that affect the lower extremities, such as ischemic ulcers, fractures, and diabetes mellitus.
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? Flattened T waves Prolonged Q-T intervals Shortened Q-T intervals Widened QRS complexes
Cardiac effects of hypocalcemia Causes oh hypocalcemia - Hypoparathyroidism, CKD, & diarrhea. Manifestations of hypocalcemia: - tingling - Numbness - Tetany - Seizures - Prolonged Q-T intervals (predisposes pt to ventricular dysrhythmias) - Laryngospasm. Hypocalcemia --> decreased myocardial contractility --> - Hypotension - Angina - Congestive HF
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse finds that the client has absent breath sounds on the left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? Tracheostomy placement Thoracentesis A CT scan of the chest Chest tube insertion
Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system. B) A thoracentesis is indicated for a client who has an increase of pleural fluid due to cancer, pleurisy, or tuberculosis or for a client who requires microscopic examination of the pleural fluid. C) While the client will require several portable chest x-rays, there is no immediate indication for a CT scan of the chest.
Common manifestations of an MI Nausea and vomiting Diaphoresis and dizziness Anxiety and feelings of doom A diminished or absent pulse (due to decreased cardiac output) Tachypnea (due to anxiety and pain)
Common manifestations of angina pectoris Chest and left arm pain that subsides with rest
A nurse is reviewing the medical record of a client who is requesting a prescription for sildenafil citrate. Which of the following data in the client's record should the nurse identify as a contraindication for the use of this medication? Diabetes mellitus Current use of isosorbide to treat heart failure Eyeglasses for presbyopia Osteoarthritis
Current use of isosorbide to treat heart failure Taking any nitrates, such as isosorbide and nitroglycerin, is a contraindication for sildenafil, a medication that treats erectile dysfunction. Taking it concurrently with nitrates can cause life-threatening hypotension.
A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider? Hypocalcemia Hyperkalemia Anemia Hypoalbuminemia
Hyperkalemia hyperkalemia can cause life-threatening cardiac dysrhythmias --> priority for the nurse to report to the provider. Expected finding with CKD - Anemia - Hyperphosphatemia - Hypocalcemia (would require reporting if the client developed muscle spasms or twitching)
A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? Instruct clients who are able to ambulate to leave. Direct staff members to close the doors and windows as each room is evacuated.
Instruct clients who are able to ambulate to leave. Clients who are able to ambulate should leave first in an evacuation process because it quickly reduces the number of clients who require evacuation assistance.
A nurse manager notes several recent conflicts among nurses on different shifts. Which of the following strategies should the nurse manager use to resolve these conflicts? Have the charge nurses for each shift get together and discuss the issues between shifts. Direct the nurses from each shift to discuss their issues and present their solutions to the nurse manager. Set up a series of meetings for all staff members to attend to discuss issues. Remain uninvolved and allow the nurses from each shift to resolve the issues among themselves.
Set up a series of meetings for all staff members to attend to discuss issues. The nurse manager is using the conflict resolution strategy of collaboration by involving everyone involved in the conflict among the staff to communicate and work together to devise and implement win-win solutions.
A nurse is providing teaching to a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client that which of the following findings is an indication of thyrotoxicosis? Weight gain Constipation Chest pain. Fatigue
Thyrotoxicosis can result if a client takes too much levothyroxine. S/S: Chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, and diaphoresis. The client should notify the provider if any of these manifestations are present.
A nurse is accepting a transfer from the PACU of a client who has had a subtotal thyroidectomy. Which of the following equipment should the nurse have available at the bedside for this client? Cardiac monitor Defibrillator Thoracotomy tray Tracheostomy tray
Tracheostomy tray With the laryngeal edema that is common post thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk for hemorrhage by increasing tension on the incision during insertion. The nurse should have a tracheostomy tray available for this client. C) Unless the client has a history of pneumothorax or is at risk for pneumothorax, a thoracotomy is not essential post thyroidectomy.
A nurse is planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse plan for this client? Walking with a staff member Playing ping-pong in the dayroom with another client Playing basketball with other clients in the gym Riding on a stationary bike alone in the fitness room
Walking with a staff member The nurse should plan to encourage the client to participate in nonthreatening, non-competitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff. B&C) The nurse should discourage the high level of stimulation of competitive activities and contact sports which can increase the client's level of anxiety and suspiciousness. D) The nurse should avoid leaving the client alone around dangerous objects due to the risk of harm to himself and to others.
A nurse is assessing a 66-year-old client during a routine physical examination at her first clinic visit and does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I had any immunizations." Which of the following responses should the nurse make? "Just in case you had the immunization before, we can't give you another one." "You'll need a series of three injections." "Let's go ahead with giving you this immunization." "This immunization is unsafe for people over the age of 65 years old."
"Let's go ahead with giving you this immunization." other options-you will need a series of 3 injections ( wrong its only 1) A) If the client is an older adult and received the immunization more than 5 years ago, it is acceptable to administer a second one. B) This immunization is a single injection, not a series. D) The Centers for Disease Control and Prevention recommends this immunization for people who are 65 years old and older.
A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include? "You might need glasses after the surgery." "You may drive home after the procedure." "Continue to wear your contact lenses until the day of the surgery." "Expect complete healing and clear vision in about a week."
"You might need glasses after the surgery." LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.
A community health nurse is planning care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A 1-week-old newborn who needs another phenylketonuria screening test A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy. A 10-day-old newborn who is small for gestational age and who requires daily weighing A 2-week-old newborn who was born at 35 weeks of gestation and weighed 2,268 g (5 lb) at discharge
A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A simple face mask A nonrebreather mask A bag-valve-mask device A nasal cannula
A nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.
A nurse in the emergency department is assessing a client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? Amylase Potassium Calcium Hematocrit
Amylase With pancreatitis, laboratory results typically show elevated amylase within 12 to 24 hr. This level remains elevated for 2 to 3 days. Pancreatitis Elevated Lipase LOW calcium (HYPOcalcemia)
A nurse is preparing to administer 100 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take? Verify with the provider about giving insulin glargine at 1700. Ensure the insulin glargine is a cloudy suspension. Request a prescription for giving insulin glargine twice daily. Use separate syringes for administering insulin glargine and NPH insulin.
Use separate syringes for administering insulin glargine and NPH insulin. The nurse should not mix insulin glargine with any other insulin. The nurse should administer the NPH insulin and insulin glargine separately. A) The nurse may administer insulin glargine at any time of the day. B) Insulin glargine is a clear solution. C) The nurse should administer insulin glargine only once in a 24-hr period.
A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada". The nurse should make which of the following age assessments for this child? 6 months old 12 months old 18 months old 24 months old
12 months old The nurse should know that the infant must be less than 18 months old due to her anterior fontanel still being open. She should assess the infant at approximately 12 months old due to the presence of six teeth. Her skills - sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and her ability to say two words (12 months) - should also help the nurse estimate the infant's age as 12 months.
A nurse is caring for a client who has dehydration and has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for the client? BUN 18 mg/dL Cap refill 1.5 sec Hct 55% Urine SG 1.001
An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? Administer aspirin. Tilt his head back and apply pressure. Have him lie down and rest. Apply continuous pressure to the lower part of his nose.
Apply continuous pressure to the lower part of his nose. With the child sitting up and breathing through his mouth, the nurse should apply continuous pressure with her thumb and forefinger to the soft lower area of the nose for 10 min. Most bleeding from the nose stops within that period. A) Aspirin can increase bleeding from the site due to its antithrombotic actions. B) Tilting the head back allows blood to flow down the back of the throat, causing nausea. C) Lying down increases the risk of aspirating the blood.
A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding? Bruising of both knees with sutures on one Arm cast for a spiral fracture of the forearm Consistent bedwetting at nap time Frequent, vague reports of a stomach ache or a headache
Arm cast for a spiral fracture of the forearm Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury.
A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the following assessments is the nurse's priority? Pulmonary function CBC Urinary output Peripheral edema
Pulmonary function Bleomycin can cause severe lung injury, including pneumonitis and pulmonary fibrosis, and it affects a significant percentage of clients receiving this medication; therefore, pulmonary function is the priority assessment.
A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6-12 months to prevent which of the following outcomes? Repeated ear infections Nutritional deficits Immune system deficits Difficulty with language acquisition
Difficulty with language acquisition Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With the cleft in the palate, these infants could develop poor speech habits.
