EXIT HESI Review, EXIT ALL HESI CUSTOM, Exit HESI 2021, Hesi exit #2

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?

***A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack (stroke

***A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

***Administer PRN nebulizer treatment. ***Obtain 12 lead electrocardiogram. ***Monitor continuous oxygen saturation.

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? a- Hypokalemia b- Ketonuria. c- Peripheral edema a- Elevated blood pressure

A

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions? a) Droplet precautions b) Enteric precautions c) Contact precautions d) Protective precautions

A

Which instruction is most important for the nurse to provide a client who is being discharge with Guillian Barre syndrome? a. Avoid exposure to respiratory infections. b. b. Use relaxation exercise when anxious c. c. Continue physical therapy at home d. d. Plan short, frequent rest periods.

A

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A.A client who is 2 days postoperative with a right total knee replacement B.A client who is scheduled for a sigmoid colostomy surgery today C.A client who has a surgical abdominal wound with dehiscence D.A client who is 1 day postoperative following a right-sided mastectomy

A (A) is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. (B) will require a high level of nursing care when returned from surgery. (C) means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. (D) requires extensive teaching and should be assigned to a more experienced nurse.

Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A.Assess the client's ability to swallow liquids. B.Obtain applesauce in which to mix the medication. C.Determine the client's food likes and dislikes. D.Auscultate the client's breath sounds.

A An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids (A) to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used (B). If a food product is used to thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the client is at risk for aspiration, determined by (A).

The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A.Increased oxygen saturation B.Increased urinary output C.Decreased apical pulse rate D.Decreased blood pressure

A Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation (A). (B, C, and D) do not indicate the desired effect of a bronchodilator

Which physiologic finding in an older adult contributes to an adverse drug reaction? A.Reduced renal excretion B.Reduced gastrointestinal motility C.Increased hepatic metabolism D.Increased risk of autoimmune disorders

A During the aging process, reduced renal function (A) is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not (C), predisposes an older adult to an increase in adverse drug reactions. (B) may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders (D) is not increased nor does it affect drug pharmacotherapeutics.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A.Failure to collect all urine specimens during the period of the study will invalidate the test. B.Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C.Dialysis is started when the GFR is lower than 5 mL/min. D.Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

A Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need to record the frequency and amount of each voiding (D) during the time span of urine collection.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A.Oral hygiene should be performed before the medication. B.Antifungal medications are available in tablet, suppository, and liquid forms. C.Candida albicans is the organism that causes the white lesions in the mouth. D.The dietary intake of dairy and spicy foods should be limited.

A HIV infection causes depression of cell-mediated immunity that allows an overgrowth of Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Mycostatin (A). (B and C) provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but (A) allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated (D).

After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A.Ensure that the client receives breakfast within 30 minutes. B.Remind the client to have a midmorning snack at 1000. C.Discuss the importance of a midafternoon snack with the client. D.Explain that the client's capillary glucose will be checked at 1130.

A Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and D) are also important nursing actions but are of less immediacy than (A).

The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A.Blood pressure of 90/56 mm Hg B.Apical pulse rate of 68 beats/min C.Potassium level of 3.3 mEq/L D.Urine output of 200 mL in 4 hours

A Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D).

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A.Encourage staff to participate in online in-service education. B.Assign staff to make sure that all equipment is thoroughly cleaned. C.Ask which staff members would like to go home for the remainder of the day. D.Notify the supervisor that the staff needs additional assignments.

A Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census (A). (B) is not the responsibility of the nursing staff. (C) is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary (D)

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A.The color of the dialysate outflow is opaque yellow. B.The dialysate outflow is greater than the inflow. C.The inflow dialysate feels warm to the touch. D.The inflow dialysate contains potassium chloride.

A Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider (A). (B and C) are desired. (D) is commonly done to prevent hypokalemia.

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis? A."Has your child had an ear infection recently?" B."Does your child seem resistant to toilet training?" C."Is your child a picky eater?" D."Do you have a family history of bone disorders?"

A Osteomyelitis can be caused by internal infections, such as otitis media (A). (B and C) are normal developmental findings for a 2-year-old. Osteomyelitis is caused by a bacterial infection, so (D) is not relevant.

A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A.A 17-year-old who is sexually active with numerous partners B.A 45-year-old lesbian who has been sexually active with two partners in the past year C.A 30-year-old cocaine user who inhales the drug and works in a topless bar D.A 34-year-old male homosexual who is in a monogamous relationship

A Rationale: (A) is at greatest risk for contracting sexually transmitted diseases, including HIV, because the greater the number of sexual partners, the greater the risk for contracting an STD. (B) comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. (C), who free-bases, would not be sharing needles, so contracting an STD is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV as long as both partners are monogamous and neither is infected (D).

A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? A.How the client examines her feet B.Which hypoglycemic medication she takes C.Who lives in the home with her D.How long she has had diabetes mellitus

A Rationale: (A) specifically relates to foot care. (B, C, and D) provide worthwhile information to obtain but do not have the importance of (A).

Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel (Plavix)? A.This drug could cause heart attack or stroke when taken by patients with certain genetic conditions. B.Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C.This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D.Clopidogrel can reduce the risk of a future heart attack when taken by patients with peripheral artery disease.

A Rationale: A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects (A). (B, C, and D) are all desired effects of the drug.

After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? A.Blood pressure, 159/98 mm Hg B.Hemoglobin A1c (HbA1c), 6% C.Creatinine level, 1.0 mg/dL D.Chronic sciatica

A Rationale: A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke (A). (B and C) are within defined parameters, and (D) is not a recognized chronic complication of diabetes.

When caring for an 80-year-old client with pneumonia, which finding is of most concern to the nurse? A.Decrease in level of consciousness B.BUN level, 20 mg/dL; creatinine level, 1.0 mg/dL C.Reports of a dry mouth and lips D.Fine crackles auscultated in lung bases

A Rationale: A decrease in level of consciousness is a sign of decreased oxygenation and requires immediate intervention (A). The others are expected findings (B, C, and D).

The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? A.Usual prepregnant weight B.Weight at the first prenatal visit C.Weight during previous pregnancy D.Recommended pattern of weight gain

A Rationale: Comparing the client's current weight with her prepregnant weight (A) allows for the calculation of weight gain. By the time of the first prenatal visit (B), she may have already gained weight. (C) may not be relevant to weight gain with the current pregnancy. (D) should be evaluated based on serial weights, not just a single current weight.

A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? A.Heart palpitations B.Leg cramps C.Nausea D.Tetany

A Rationale: Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency (A). (B and C) are also of concern but are not as life threatening. (D) is a symptom of hypocalcemia.

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin (Pitocin) infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A.Maternal temperature B.Fetal blood pressure C.Maternal respiratory rate D.Fetal heart rate

A Rationale: Maternal temperature (A) should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. (B) cannot be established with standard bedside monitoring. (C) is not specifically related to ROM. (D) is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.

A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone (Risperdal). The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain? A.Compliance with medication regimen B.Current thyroid-stimulating hormone (TSH) level C.Occurrence of mania or depression D.A 24-hour diet and exercise recall

A Rationale: Medication compliance (A) is most important for the treatment of psychotic disorders and, because Risperdal is associated with weight gain, it is probable that the client is complying with the treatment plan. The TSH level (B) indicates thyroid function, which regulates basal metabolic rate and influences weight. It is important to obtain information about occurrences of mania and depression (C) since the last visit, but if the client is compliant with the medication regimen, these symptoms are likely to have been controlled. Diet and exercise (D) should also be assessed, but weight gain is a likely indicator of medication compliance.

An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group.

A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D).

The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? A.O2 saturation, 89% B.Reports diplopia C.Ptosis to left eye D.Difficulty speaking

A Rationale: Respiratory failure is a life-threatening complication that can occur with myasthenia gravis (A). (B, C, and D) are signs of the disease but are not as life threatening as decreased oxygen saturation.

A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the client has increased photosensitivity. C.Provide comfort measures for sore muscles. D.Assess the client for visual and auditory hallucinations.

A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A).

Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine

A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).

The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the licensed practical nurse (LPN)? A.A client with nausea who needs a nasogastric tube inserted B.A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D.A client who is ready for discharge who needs discharge teaching

A Rationale: This client has a need for a skill that is within the scope of practice for the LPN (A). Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated (B, C, and D).

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A.Team 1: RN team leader, PN; team 2, PN team leader, UAP B.Team 1, RN team leader, UAP; team 2, PN team leader, PN C.Team 1, PN team leader, PN; team 2, RN team leader, UAP D.Team 1, PN team leader, UAP; team 2, RN team leader, PN

A Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN (A). Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. (B, C, and D) do not use the expertise of the nursing staff for the high-risk clients.

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A.Check the client's blood pressure. B.Teach her to elevate her feet when sitting. C.Obtain a 24-hour diet history to evaluate for the intake of salty foods. D.Assess the fetal heart rate.

A The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal.

The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A."I take aspirin for my pain." B."I frequently eat fruit and drink fruit juices." C."I drink a great deal of water, so I have to get up at night to urinate." D."I observe my skin daily to see if I have an allergic rash to the medication."

A The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D).

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A.Help the client dangle his legs. B.Apply compression stockings. C.Assist with passive leg exercises. D.Ambulate three times a day.

A The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B.Pneumonia, with a sputum culture of gram-negative bacteria C.Urinary tract infection, with positive blood cultures D.Culture of a diabetic foot ulcer shows gram-positive cocci

A The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.

A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A.Move objects out of the child's immediate area. B.Quickly slip soft restraints on the child's wrists. C.Insert a padded tongue blade between the teeth. D.Place in the recovery position before going for help.

A The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this may cause more trauma. Objects should not be placed in the child's mouth (C) because it may pose a choking hazard. Although (D) should be implemented after the seizure, the nurse should not leave the child during a seizure to get help.

A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A.The client's usual sleeping pattern B.Whether the client smokes C.How much liquid the client consumes before bedtime D.The amount of caffeine that the client consumes during the day

A The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia (A). (B, C, and D) provide additional information after (A) is ascertained.

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A.50 mg/dL B.80 mg/dL C.110 mg/dL D.140 mg/dL

A The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL (A), requires the most immediate intervention to prevent loss of consciousness. Normal (B) and slightly elevated levels, such as 110 or 140 mg/dL (C and D), do not require immediate intervention.

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A.Save the next urine sample. B.Restrict oral fluid intake. C.Strain all voided urine. D.Reduce physical activity.

A The nurse should instruct the client to save the next urine sample (A) for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.

The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform? A.Examine for clamp closures. B.Irrigate with a larger syringe. C.Assess for signs of infection. D.Flush the line with heparin.

A Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a central line, so the line should be assessed for closed clamps (A) first. Irrigation with a larger syringe (B) will not alleviate the cause for the resistance and can rupture the line. A central line infection (C) should not cause resistance while flushing the line. The CVC should be flushed with normal saline (D) or a diluted solution of heparin (10-100 U/mL) after (A) is completed, if necessary.

144. At shift change in the emergency room several pediatric clients arrive within minutes of each other. Which child requires the most immediate intervention by the nurse? a. A crying 5 year old with a scalp wound whose father is holding a blood soaked towel to the head. b. A year old with Down syndrome who is pale and is sleeping in the mother's arms c. A 4 year old with a barking cough and a flushed appearance who is sitting between both parents d. A 2 year old with an audible stridor who is drooling and sitting up in the mother's arms.

A 2 year old with an audible stridor who is drooling and sitting up in the mother's arms.

388. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

A 30 year old depressed client who admits to suicide ideation.

A patient with a hemothorax has a posterior chest tube located laterally in the fifth intercostal space connected to a water-seal drainage system. Preprocedure vital signs were: temperature 98.6° F, pulse 110, respiration 26 and shallow, blood pressure 94/52, and oxygen saturation 87%. The nurse is evaluating the patient's outcome. The health care provider should be notified of which of the following findings? (Select all that apply.) A. Asymmetrical chest movement. B. Bubbling in water-seal chamber immediately after chest tube insertion. C. Temperature 98.0° F, pulse 80, respiration 20, blood pressure 124/80, pulse oximetry 93%. D. 500 mL of drainage in 24 hours. E. Temperature 98.0° F, pulse 124, respiration 28, blood pressure 80/50, pulse oximetry 85%. F. Bright red drainage 8 hours after insertion in the collection chamber.G. Drainage changing to serous color.

A E F

Peptic Ulcer Disease

A break or ulceration in the protective mucosal lining of the lower esophagus, stomach, or duodenum

When encouraging a client to cough and deep breath after a bilateral mastectomy, the client says, "Leave me alone! Don't you know I'm in pain?" What is the nurse's best response? A) "I know it hurts to cough, but try to use the IS." B) "We'll start this tomorrow; I will give you something for your pain." C) "I understand that you are in pain; rest now, and I'll come back later." D) "Your pain is to be expected, but you must attempt to expand your lungs."

A) "I know it hurts to cough, but try to use the IS."

The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A) "I take aspirin for my pain." B) "I frequently eat fruit and drink fruit juices." C) "I drink a great deal of water, so I have to get up at night to urinate." D) "I observe my skin daily to see if I have an allergic rash to the medication."

A) "I take aspirin for my pain." - The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D).

Before discharge, a client who had a colostomy for colorectal cancer questions the nurse about resuming activity. What should the nurse teach the client about activity? A) "With guidance, a near-normal lifestyle, include complete sexual function, is possible." B) "Activities of daily living should be resumed as soon as possible so you avoid being depressed." C) Most sports activities, except for swimming, can be resumed based on your overall physical condition." D) "After surgery, changes in activities must be made to accommodate for physiologic changes caused by the operation."

A) "With guidance, a near-normal lifestyle, include complete sexual function, is possible."

A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client's trachea routinely. What is the rationale for this nursing intervention? A) A mediastinal shift may have occurred B) Nodular lesions may demonstrate metastasis C) Tracheal edema may lead to an obstructed airway D) The cuff on the endotracheal tube may be overinflated

A) A mediastinal shift may have occurred

A nurse is caring for a client with diabetes who is scheduled for a radiographic study requiring contrast. What should the nurse expect the HCP to prescribe? A) Acetylcysteine before the test B) Renal-friendly contrast medium for the test C) Forced diuresis with mannitol after the test D) Hydration with dextrose and water throughout the test

A) Acetylcysteine before the test - Acetylcysteine is an antioxidant that scavenges oxygen free radicals, which are released when contrast medium causes cell death to renal tubular tissue; it also induces slight vasodilation.

The nurse places a heating pad on the lower leg of a client with peripheral vascular disease (PVD). When the heating pad is removed, the client's skin is blistered and a full-thickness burn is evident. What consequence can occur based on the nurse's action? A) All elements are present to find the nurse liable for damages. B) The injury was not foreseeable therefore the nurse is not liable. C) Client harm occurred which is enough evidence to prove liability. D) The standard of care was not breached so the nurse is not liable.

A) All elements are present to find the nurse liable for damages. - The nurse has a duty to deliver safe care. If that duty is breached, the injury foreseeable, and the client suffers harm, then the elements for establishing liability are present (A). In caring for a client with PVD, the nurse should anticipate that heat injury (B) is possible and provide the standard of care to prevent harm (D). Client harm (C) represents only one element and should not be the lone criteria for determining liability.

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? A) Call the healthcare provider immediately if his nail beds appear blue. B) Check his fingers hourly for the first 48 hours to see that he is able to move them without pain. C) Be sure his arm remains above his heart for the first 24 hours. D) Take his temperature q4h for the next two days and call if an elevation is noted.

A) Call the healthcare provider immediately if his nail beds appear blue. - Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively--and might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child's temperature q4h unless indicated by other symptoms.

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

A) Decreased carbohydrates and fat ***B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? A) Description of vomiting episodes in past 24 hours. B) Number of wet diapers in last 24 hours. Incorrect C) Feeding and sleep schedule. D) Amount of formula consumed during the past 24 hours.

A) Description of vomiting episodes in past 24 hours. - A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A) Encourage the client to see the clinic's grief counselor. B) Determine if the client has a family history of suicide attempts. C) Inquire about whether the life partner was suffering from AIDS. D) Consult with the health care provider about the client's need for antidepressant medications.

A) Encourage the client to see the clinic's grief counselor. - The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. (B) is indicated, but is not a high-priority intervention. (C) is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated (D), depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A) Failure to collect all urine specimens during the period of the study will invalidate the test. B) Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C) Dialysis is started when the GFR is lower than 5 mL/min. D) Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

A) Failure to collect all urine specimens during the period of the study will invalidate the test. - Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need to record the frequency and amount of each voiding (D) during the time span of urine collection.

The cervix of a client in labor is dilated 8 cm. She tells the nurse that she has the desire to push and is becoming increasingly uncomfortable. She requests pain medication. How should the nurse respond? A) Help her to take panting breaths B) Prepare the birthing bed for the birth C) Assist her out of bed to the bathroom D) Administer the prescribed butorphanol (Stadol)

A) Help her to take panting breaths

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A) Help the client dangle his legs. B) Apply compression stockings. C) Assist with passive leg exercises. D) Ambulate three times a day.

A) Help the client dangle his legs. - The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

The nurse teaches a class on bioterrorism. Which method(s) of transmission is(are) possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A) Inhalation of powder form B) Handling of infected animals C) Spread from person to person through coughing D) Eating undercooked meat from infected animals E) Direct cutaneous contact with the powder

A) Inhalation of powder form B) Handling of infected animals D) Eating undercooked meat from infected animals E) Direct cutaneous contact with the powder - Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A) Monitor maternal vital signs for hemorrhage. B) Instruct the woman to report any contractions. C) Ensure that the woman has a full bladder prior to beginning. D) Monitor fetal heart rate for 1 hour after the procedure. E) Place the client in a side-lying position.

A) Monitor maternal vital signs for hemorrhage. B) Instruct the woman to report any contractions. D) Monitor fetal heart rate for 1 hour after the procedure. - These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).

A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.) A) Monitor the the infant's weight and number of wet diapers per day. B) Increase the infant's intake per feeding by 1 to 2 ounces per week. C) Mix the dose of prophylactic antibiotic in a full bottle of formula. D) Allow the infant to rest and refeed on demand or every 2 hours. E) Use a softer nipple or increase the size of the nipple opening.

A) Monitor the the infant's weight and number of wet diapers per day. B) Increase the infant's intake per feeding by 1 to 2 ounces per week. D) Allow the infant to rest and refeed on demand or every 2 hours. E) Use a softer nipple or increase the size of the nipple opening. - Correct responses are (A, B, D, and E). Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day (A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4-months of age (B). Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake (D). A softer (preemie) nipple or a larger slit in the nipple (E) helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is consumed.

A nurse is assessing a client who is being admitted for a surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? Select all that apply. A) Painful intercourse B) Crampy abdominal pain C) Bearing-down sensation D) Urinary stress incontinence E) Recurrent UTI's

A) Painful intercourse C) Bearing-down sensation

Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. A) Pancreas B) Thyroid gland C) Adrenal cortex D) Adrenal medulla E) Parathyroid gland

A) Pancreas B) Thyroid gland C) Adrenal cortex - The pancreas secretes insulin and glucagon, which affects the body's metabolism of carbohydrates, proteins, and fats. The thyroid gland secretes thyroid hormones T3 and T4 that regulate carbohydrates, proteins, and fat metabolism. Cortisol is a glucocorticoid secreted by the adrenal cortex that affects carbohydrates, proteins, and fat metabolism. Adrenal medulla secretes catecholamines, which do not affect metabolism of carbohydrates, proteins, and fats. Hormones secreted by the parathyroid gland mainly regulate calcium and phosphorus metabolism.

A nurse is counseling a couple in the fertility clinic. Which aspect of the protocol is the most stressful for the couple? A) Planning when to have intercourse B) Obtaining the necessary specimens C) Visiting the fertility clinic frequently D) Taking daily basal body temperatures

A) Planning when to have intercourse

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? A) Polyuria and polydipsia. B) Lethargy and fatigue. C) Increased facial hair. D) Facial bone structure changes.

A) Polyuria and polydipsia. - Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12-year-old males.

A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include in the rationale for this diet? A) Repairs tissues B) Slows peristalsis C) Corrects the anemia D) Improves muscle tone

A) Repairs tissues

Minocycline (Minocin), 50 mg PO every 8 hours, is prescribed for an adolescent girl diagnosed with acne. The nurse discusses self-care with the client while she is taking the medication. Which teaching points should be included in the discussion? (Select all that apply.) A) Report vaginal itching or discharge. B) Take the medication at 0800, 1500, and 2200 hours. C) Protect skin from natural and artificial ultraviolet light. D) Avoid driving until response to medication is known. E) Take with an antacid tablet to prevent nausea. F) Use a nonhormonal method of contraception if sexually active.

A) Report vaginal itching or discharge. C) Protect skin from natural and artificial ultraviolet light. D) Avoid driving until response to medication is known. F) Use a nonhormonal method of contraception if sexually active. - Correct selections are (A, C, D, and F). Adverse effects of tetracyclines include superinfections, photosensitivity, and decreased efficacy of oral contraceptives. Therefore, the client should report vaginal itching or discharge (A), protect the skin from ultraviolet light (C), and use a nonhormonal method of contraception (F) while on the medication. Minocycline (Minocin) is known to cause dizziness and ataxia, so until the client's response to the medication is known, driving (D) should be avoided. Tetracyclines should be taken around the clock (B) but exhibit decreased absorption when taken with antacids, so (E) is contraindicated.

The nurse is preparing to administer amphotericin B (Fungizone) IV to a client. What laboratory data is most important for the nurse to assess before initiating an IV infusion of this medication? A) Serum potassium level B) Platelet count C) Serum creatinine level D) Hemoglobin level

A) Serum potassium level - The nurse should obtain baseline potassium levels (A) prior to beginning drug therapy because amphotericin B (Fungizone) changes cellular permeability, allowing potassium to escape from the cell, which could lead to a decrease in the serum potassium level and severe hypokalemia. (B, C, and D) are helpful laboratory values, but they do not have the importance of (A) in determining if amphotericin B (Fungizone) can be administered safely via IV infusion

Oxytocin (Pitocin) augmentation via IV piggyback (IVPB) is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply. A) Stop the infusion B) Turn the client on her side C) Notify the HCP D) Verify the length of contractions E) Administer oxygen via a face mask

A) Stop the infusion B) Turn the client on her side C) Notify the HCP D) Verify the length of contractions E) Administer oxygen via a face mask

A client is being treated for osteoporosis with alendronate (Fosamax), and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client teaching has been effective? A) Take medication, go for a 30 minute morning walk, then eat breakfast. B) Take medication, rest in bed for 30 minutes, eat breakfast, go for morning walk. C) Take medication with breakfast, then take a 30 minute morning walk. D) Go for a 30 minute morning walk, eat breakfast, then take medication.

A) Take medication, go for a 30 minute morning walk, then eat breakfast. - Alendronate (Fosamax) is best absorbed when taken thirty minutes before eating in the morning. The client should also be advised to remain in an upright position for at least thirty minutes after taking the medication to reduce the risk of esophageal reflux and irritation. (A) is the best schedule to meet these needs. (B, C, and D) do not meet these criteria.

Which situation requires intervention by the nurse who is caring for a terminally ill client in a hospital? A) The case manager notifies the family that the critical pathway requires transfer to a hospice facility. B) The case manager notifies the social worker of the client's financial needs related to hospice care. C) The social worker describes the client's feelings of grief to the spiritual counselor. D) The social worker provides information about long-term care facilities to the client.

A) The case manager notifies the family that the critical pathway requires transfer to a hospice facility. - Critical pathways provide care guidelines, rather than required methods of care. The nurse should intervene in the situation described in (A) to ensure that the client and family are aware of options available. (B, C, and D) reflect appropriate actions by members of the interdisciplinary team, and require no intervention by the nurse.

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A) The color of the dialysate outflow is opaque yellow. B) The dialysate outflow is greater than the inflow. C) The inflow dialysate feels warm to the touch. D) The inflow dialysate contains potassium chloride.

A) The color of the dialysate outflow is opaque yellow. - Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider (A). (B and C) are desired. (D) is commonly done to prevent hypokalemia.

A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?

A) The emergency room nurse. ***B) His case manager. C) The clinic healthcare provider. D) His support group sponsor.

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? A) Type of reaction to loud noises. B) Any surgeries on the ears since birth. C) Drainage from the infant's ears. D) Number of ear infections since birth.

A) Type of reaction to loud noises. - Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.

A client is admitted to the surgical unit from the PACU with a Salem sump NG tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? A) Use NS to irrigate the tube B) Employ sterile technique when irrigating the tube C) Withdraw the tube quickly when decompression is terminated D) Allow the client to have small sips of ice water unless nauseated

A) Use NS to irrigate the tube

A female client with rheumatoid arthritis take ibuprofen (Motrin) 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol (Cytotec) 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching? A) Use contraception during intercourse. B) Ensure the Cytotec is taken on an empty stomach. C) Encourage oral fluid intake to prevent constipation. D) Take Cytotec 30 minutes prior to Motrin.

A) Use contraception during intercourse. - Cytotec, a synthetic form of a prostaglandin, is classified as pregnancy Category X and can act as an abortifacient, so the client should be instructed to use contraception during intercourse (A) to prevent loss of an early pregnancy. (B) is not necessary. A common side effect of Cytotec is diarrhea, so constipation prevention strategies are usually not needed (C). Cytotec and Motrin should be taken together (D) to provide protective properties against gastrointestinal bleeding.

A nurse is teaching a client with gout about foods that are low in purine. Which of the following would be a good choice for the client? SATA A) Low fat dairy B) Wine C) Eggs D) Aged cheese E) Nuts

A, C, E Low-fat dairy, Eggs, Nuts

A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) A.Abdominal obesity B.Sedentary lifestyle C.History of hypoglycemia D.Hispanic or Asian ethnicity E.Increased triglycerides

A,B,D,E Rationale: Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).

The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individual(s)? (Select all that apply.) A.An Rh-negative woman who has had a miscarriage at 24 weeks B.The father of a baby of an Rh-positive fetus C.An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs' test D.An Rh-positive infant within 72 hours after birth E.An Rh-negative mother with a negative antibody titer at 28 weeks

A,C,E Rationale: (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D).

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? A-Provide supplemental oxygen B-Auscultate bilateral lung fields C-Administer a nebulizer treatment D-Reinforce occlusive CT dressing E-Give PRN dose of pain medication

A-Provide supplemental oxygen B-Auscultate bilateral lung field D-Reinforce occlusive CT dressing

The nurse identifies an electrolyte imbalance, an elevated central venous pressure (CVP) and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with full thickness burns. Which intervention should the nurse implement?

A. Document abdominal girth. B. Record usual eating patterns. C. Measure ankle circumference. ***D. Measure and document urinary output.

Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient?

A. Dysuria, frequency, and urgency B. Back pain, nausea, and vomiting ***C. Hypertension, oliguria, and fatigue D. Fever, chills, and right upper quadrant pain radiating to the back Mild to moderate HTN may result from sodium or water retention and inappropriate renin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider?

A. Slight blood-tinged sputum B. Dyspnea and dysphagia C. Sore throat and hoarseness ***D. No gag reflex after thirty minutes

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3 year old son for wetting his pants. What initial action should the nurse take?

A. Suggest that the mother consult a pediatric nephrologists B. Provide disposable training pants while calming the mother C. Refer the mother to a community parent education program ****D. Inform the mother that toilet training is slower for boys

The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution?

A. Surgical mask, clean gloves, and gown ***B. Properly fitted N95 respirator or mask C. Sterile gloves and gown D. Goggles, clean gloves, and gown

A patient has returned from the operating room with a chest tube in his sixth intercostal space with orders to connect the patient to wall suction. The patient has a three-chamber water-seal system. Eight hours later the nurse finds the patient complaining of increased chest pain, a respiratory rate of 40, and a pulse of 110. The water-seal chamber is dry. The patient is in obvious distress. What should the nurse suspect as the primary cause for the respiratory distress? A. There is no water in the water-seal chamber. B. The patient's chest tube has become dislodged. C. The wall suction needs to be increased. D. The patient is breathing shallowly and avoiding coughing.

A. There is no water in the water-seal chamber.

The nurse is visiting a senior client to complete a fall assessment. Which observations indicate that the client would benefit from instructions regarding balance and positioning? (Select all that apply.)

A. Wide stance.B. Knees are locked.C. Weight is focused on balls of the feet.D. Weight is focused on heels of the feet.E. Chest is slightly further back than abdomen. ANS: B, C, D, E

Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel (Plavix)? A.This drug could cause heart attack or stroke when taken by patients with certain genetic conditions. B.Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C.This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D.Clopidogrel can reduce the risk of a future heart attackwhen taken by patients with peripheral artery disease.

A.This drug could cause heart attack or stroke when taken by patients with certain genetic condition

59. The nurse is verifying a blood transfusion for a client whose blood type is A positive. Which blood type is incompatible for this client? a. O, Rh negative b. AB, RH positive c. A, Rh negative d. O, Rh positive

AB, RH positive

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A.Hourly urine output B.Bladder distention C.Urinary incontinence D.Intraoperative bladder decompression E.Urine sample for culture

ABD Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A.Monitor maternal vital signs for hemorrhage. B.Instruct the woman to report any contractions. C.Ensure that the woman has a full bladder prior to beginning. D.Monitor fetal heart rate for 1 hour after the procedure. E.Place the client in a side-lying position.

ABD These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).

The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A.Increase in T3 and T4 B.Decrease in heart rate C.Increase in TSH D.Decrease in urine output E.Decrease in periorbital edema

ABE Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine (Synthroid) (B and C). Levothyroxine does not affect urine output (D).

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treatments for dehydration in a 36-month-old child? (Select all that apply.) A.Record wet diapers. B.Assess for sunken fontanels. C.Examine skin turgor. D.Observe mucous membranes.

ACD All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, and D), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A.Confusion B.Peripheral edema C.Crackles in the lungs D.Dyspnea E.Distended neck veins

ACD Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion (A, C, and D). (B and E) are associated with right-sided heart failure.

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A.Use lanolin to moisturize the tops and bottoms of the feet. B.Soak the feet in warm water for at least 1 hour daily. C.Wash feet daily and dry well, particularly between the toes. D.Use over-the-counter products to remove corns and calluses. E.Wear leather shoes that fit properly.

ACE (A, C, and E) are therapeutic interventions for foot care in the diabetic patient. (B and D) are contraindicated and could cause foot infection or injury.

A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the aPTT values should the nurse expect?

ANS- 45 seconds This value is above the expected reference range of 30-40 seconds and indicates a risk for spontaneous bleeding, which is a manifestation of hemophilia A.

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

ANS- Altered consciousness within the first 24 hours after injury.

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is:

ANS- The visualization of the inside of the bladder with an instrument connected to a source of light."

A nurse receives a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement? a. Encourage the client to be calm and relax for a little while b. Assist the client to identify stimuli that precipitates the activity. c. Allow time for the behavior and then redirect the clients to other activities. d. Teach the client thought stopping techniques and ways to refocus.

ANS-C

A nurse is providing teaching for the parents of a school-age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, "We are unable to say anything to convince him that ___ is impossible." Which of the following is an appropriate suggestion?

ANS-Encourage the child to be involved with the soccer team as the coach's assistant or team manger

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:

ANS-Encouraging the client to deep-breathe, cough, and use an incentive spirometer

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction?

ANS-Notify all health care providers (HCPs) of the history of infective endocarditis before any invasive procedures.

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

ANS-Rapid onset of decreased level of consciousness

516. What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Achieve satisfactory pain control.

590. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement?

Acknowledge the client's stress and suggest that she consider respite care.

A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?

Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment.

The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?

Activity intolerance related to postoperative pain.

Which condition is appropriate when considering common post infectious renal diseases in childhood?

Acute glomerulonephritis

30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour

A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour

18. An adult female client with chronic kidney disease (CKD) is becoming increasingly restless and is hyperventilating. Urine output is 25 ml/hr and urine pH is 4.5. On admission, her arterial blood gases (ABGs) are: pH 7.20, PaCO2 37 mEq/L, and HCO3 14 mEq/L. Which action should the nurse implement? a) Administer IV solution with sodium bicarbonate b) Flush AV fistula with 0.9 Sodium chloride c) Give laxatives or an enema as client requests d) Maintain the client NPO (nothing by mouth)

Administer IV solution with sodium bicarbonate

79. A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take?

Administer Naxolone IV

566. A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks:

Administer Oxygen via face mask

129. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.

314. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache

340. While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?

Administer a nebulizer Treatment

130. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Administer a prescribed analgesia for pain.

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

Administer the dose as prescribed. Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose.

271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Administer the medication as prescribed with a glass of water

192. The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?

Administer the medication via the oral route as prescribed

529. A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

Administered Nebulized Epinephrine

34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?

Advise the client that assignments are not based on clients requests

498. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

Advise the client to empty her bladder fully when she first voids

434. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?

Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

360. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take?

Allow the impaired nurse to return to work and monitor medication administration

A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take?

Allow the impaired nurse to return to work and monitor medication administration

536. A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?

Allow the infant to rest before feeding

538. A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

Allow time for the behavior and then redirect the clients to other activities

414. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

57. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

53. Which nursing problem is best for the nurse to use when planning care for a client with early Parkinson's disease? a. Impaired physical mobility b. Ineffective airway clearance c. Altered cardiac output d. Altered nutrition: less than body requirements

Altered nutrition: less than body requirement

119. A client who does not appear to be pregnant comes to the antepartal clinic and tells the nurse that she thinks she may be "about two months pregnant". If the client is pregnant, which sign may the nurse expect her to exhibit? a) Lightening b) Quickening c) Edema of the feet d) Amenorrhea

Amenorrhea

What are some of the more common complications of bulimia nervosa (BN)?

Amenorrhea Fluid/electrolyte imbalances Dehydration Seizures Erosion of tooth enamel, tooth decay Salivary gland and pancreatic inflammation Dysfunctional bowel

19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?

An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

43. Which client is at the greatest risk for developing delirium?

An adult client who cannot sleep due to constant pain.

Which client is at the greatest risk for developing delirium?

An adult client who cannot sleep due to constant pain.

After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response?

An elevated erythrocyte sedimentation rate (ESR) is indicative of active inflammation, so the nurse should determine if the ESR has normalized (D)

361. In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?

An immobile client receiving low molecular weight heparin q12 h.

In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?

An immobile client receiving low molecular weight heparin q12 h.

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

An older client post-stroke who is aphasic with right-sided hemiplegia

378. After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?

An older man whose sheets are damped each time he is turned.

225. Based on principles of asepsis, the nurse should consider which circumstance to be sterile?

An open sterile Foley catheter kit set up on a table at the nurse waist level

61. Based on the principles of asepsis, the nurse should consider which circumstance to be sterile? e) A wrapped, unopened sterile 4x4 gauze pad placed on a damp table f) An open sterile Foley catheter kit set up on a table at the nurse's waist level g) A one-inch border around the edges of a sterile field set up in the operating room h) A sterile syringe is placed on sterile area as the burse reaches over the sterile field

An open sterile Foley catheter kit set up on a table at the nurse's waist level

90. While completing assessment of a peripheral IV with a vasopressors infusing, the nurse recognizes that the extremity is swollen, painful, and pale. What actions should the nurse implement? (select all that apply.) a) Apply cold compressed to the infiltration site b) Inject a subcutaneous antidote per protocol c) Elevate the affected extremity on several pillows d) Stop the IV infusion pump before discontinuing the infusion e) Aspirate remaining vasopressors form IV catheter before withdrawal

Apply cold compressed to the infiltration site Elevate the affected extremity on several pillows

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

Apply cold compresses to both breasts for comfort

546. A multigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client's 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement?

Apply counter-pressure to the sacral area

595. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?

Apply downward manual pressure at the suprapubic regions.

95. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?

Apply light pressure over the area.

A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care?

Ask client to describe triggers of anger.

74. A 4-year-old who fell off a tricycle is admitted to the hospital for observation. Which action should the nurse implement to facilitate the child's cooperation during the admission assessment? a) Allow the child to play with an empty syringe without the needle b) Explain the function of each organ during the steps of the assessment c) Have the parent hold the child's arms during the head to toe assessment d) Ask the child to blow out the pen light and turn it off to stimulate success.

Ask the child to blow out the pen light and turn it off to stimulate success.

399. A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement?

Ask the client about his expected goals for the hospitalization

127. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? a) Remind the client to hold his breath after inhaling the medication b) Confirm that the client has correctly shaken the inhaler c) Affirm that the client has correctly positioned the inhaler d) Ask the client if he has a spacer to use for this medication

Ask the client if he has a spacer to use for this medication

406. A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?

Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?

Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

A female client who is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Ask the client to discuss "do not resuscitate" with her healthcare

29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Ask the client to discuss "do not resuscitate" with her healthcare provider

To assess a client's pupillary response to accommodation, a nurse should perform which activity?

Ask the client to look at a distant object and then at an object held 10 cm from the nose.

128. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

Ask the client what he is thinking about at his time.

454. While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first?

Ask the client when a family member last visited her.

37. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? a) Include the family in client's care b) Request the chaplain's presence c) Ask the family to identify a specific spokesperson d) Page the healthcare provider to speak with family.

Ask the family to identify a specific spokesperson

462. On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?

Ask the nurse to return home and get her prescription eyeglasses for work.

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Ask the older brother how he felt during the incident.

79. When administering brompheniramine maleate (Demetane Extentab) the nurse is told by the male client that he cannot swallow tablets." Which intervention should the nurse implement? a) Ask the pharmacist to send medication in liquid form b) Crush tablet and mix with small amount of pudding c) Document that the client cannot take the prescription d) Document the client's refusal to take medication

Ask the pharmacist to send medication in liquid form

511. The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?

Aspirin content.

The nurse is taking a client's blood pressure and observes carpal spasms after the sphygmomanometer cuff is inflated. What action should the nurse implement next?

Asses the client recent serum calcium level

216. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

417. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

307. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement?

Assess compliance with routine prescriptions.

47. During a clinic visit, a male client with heart failure (HF) reports that he has gained 4 pounds in the last 3 days. Which action should the nurse implement? e) Recommend controlled portions at mealtimes f) Encourage a reduced intake of table salt g) Auscultate all lung fields for fine crackles h) Assess for bilateral pitting pedal edema

Assess for bilateral pitting pedal edema

497. The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply

Assess the client for self-care ability Provide pain medication instructions Teach care of ostomy to care provider

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply

Assess the client for self-care ability Provide pain medication instructions Teach care of ostomy to care provider.

Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test?

Assess the newborn's feeding patterns of formula or breast milk which has "come in."

119. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first?

Assess the surroundings for noise and distractions.

What is the nurse's FIRST ACTION and HIGHEST priority if a medication error has occurred:

Assessing the patient's physiologic status and ensuring their safety.

51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

Assign a practical nurse (LPN) to determine if an apical radial deficit is present

125. A woman at 24-weeks gestation who has a fever, body aches, and had been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest priority? a) Vital signs q4 hours b) Obtain specimens for culture c) Ringers Lactate IV 125 mL/8hours d) Assign private room

Assign private room

324. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?

Assist client in identifying goals for the day.

86. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond?

Assist the client in developing a goal of managing the pain

89. The nurse determines that an elderly client with pneumonia has a nursing diagnosis of, "Altered nutrition, less than body requirements." What instruction should the nurse give the UAP assisting with the care of this client? a) Listen to the client's breath sounds and after meals b) Assist the client in selecting high protein foods on the menu c) Offer to assist the client with meal preparation and feeding d) Thicken the client's liquids if aspiration seems likely

Assist the client in selecting high protein foods on the menu

597. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

Assist the client to sharply flex her thighs up again the abdomen.

57. The nurse assesses a child in a 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome? (Click the correct location).

At the cast

A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?

Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time.

81. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating a) A paced rhythm with 100 capture after pacemaker replacement b) Normal sinus rhythm and complaining of chest pain c) Atrial fibrillation with congestive heart failure and complaining of fatigue d) Sinus tachycardia 3 days after a myocardial infarction

Atrial fibrillation with congestive heart failure and complaining of fatigue

The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What is the best response for the nurse to provide?

Atropine may be prescribed to increase the automaticity of the SA node and prevent a dangerous reduction in HR during surgical anesthesia.

203. While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement?

Attempt to distract the client with general conversation

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?

Avoid crowds for first two months after surgery.

608. The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)

Avoid eating grapefruit or drinking grapefruit juice. Report changes in the use of daily supplements Notify you heal care provider if your skin looks yellow

571. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care?

Avoid foods that caused gas before the colostomy

16. Which instruction is most important for the nurse to include in the discharge teaching plan of a client who had a prostatectomy three days ago? a) Ambulate and exercise as tolerated b) Read written follow up instructions c) Avoid lifting 20 pounds for 6 weeks d) Increase fluid intake to one quart daily

Avoid lifting 20 pounds for 6 weeks

A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide?

Avoid tight-fitting clothing and do not use bubble-bath or bath salts.

124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? a- Olanzapine b- Divalproex. c- Lorazepam d-Fluoxetine

B

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? a- Jaundice skin tone b- Muffled heart sounds c- Pitting peripheral edema d- Bilateral scleral edema

B

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client‟s status, what priority action should the nurse implement? a- The impending signs of death should be documented b- The client‟s need for pain medication should be determined. a-The nurse manager should be updated on the client‟s status d- The client‟s status should be conveyed to the chaplain

B

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client‟s serum laboratory values requires intervention by the nurse? a- Total calcium 9 mg/dl (2.25 mmol/L SI) b- b- Creatinine 4 mg/dl (354 micromol/L SI) c- c- Phosphate 4 mg/dl (1.293 mmol/L SI) d- d- Fasting glucose 95 mg/dl (5.3 mmol/L SI)

B

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? a. A) "I have a sharp pain in my chest when I take a breath." b. B) "I have been coughing up foul-tasting, brown, thick sputum." c. C) "I have been sweating all day." d. D) "I feel hot off and on. ANS-B

B

Hugo has a fraternal twin named Franco who is unaffected by mental illness even though they were raised in the same dysfunctional household. Franco asks the nurse, "Why Hugo and not me?" The nurse replies: a. "Your father was probably less abusive to you." b. "Hugo likely has a genetic vulnerability." c. "You probably ignored the situation." d. "Hugo responded to perceived threats by focusing on an internal world."

B

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? a. A) Nausea and vomiting b. B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) c. C) Diffuse macular rash d. D) Muscle tenderness

B

While assessing an older client with a 12-year history of diabetes, the client complains of a decreased sensory perception in both of their feet. Which action should the nurse take first? A. Test sensory perception in the client's extremities. B. Examine the feet for injuries or wounds. C. Educate the client about peripheral neuropathy. D. Document the client's symptom and complaint

B

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A.Assign the PNs to perform am care and assist with feeding the clients. B.Assign the UAPs to take vital signs and obtain daily weights. C.Assign the RNs to answer the call lights and administer all medications. D.Assign the PNs to assist health care providers on rounds and perform glucometer checks.

B A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN (A). All team members can answer call lights and PNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A.Flex the hips and knees and align the knees with the client's knees for safety. B.Allow the client to sit on the side of the bed for a few minutes before transferring. C.Place the client's weight-bearing or strong leg forward and the weak foot back. D.Grasp the transfer belt at the client's sides to provide movement of the client.

B A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes (B) before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity (A and C) reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt (D) provides a secure hold to prevent sudden falls.

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A.Fluid and electrolyte balance is maintained. B.Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C.Abdominal pain is relieved and perianal skin integrity is maintained. D.Normal bowel patterns are reestablished.

B A priority goal for the client with infectious diarrhea caused by Clostridium difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission (B). (A and C) are goals dependent on the return of the client's normal bowel pattern (D).

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A.Inspect the dressing over the puncture site and under the client for bleeding. B.Take the vital signs to determine the client's response for a potential blood loss. C.Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D.Assess the client's pain level to determine the need for analgesic medication.

B After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure (B). Although (A, C, and D) should be implemented after the procedure, the first action is to obtain a baseline assessment.

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of Regular and NPH insulin. Which statement indicates that the client needs further instruction? A."I should balance my daily exercise with my dietary intake and insulin dosages." B."When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C."I should inject my insulin into a different site to reduce the development of scar tissue." D."I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."

B Aspiration (B) is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. (C) helps minimize tissue atrophy, which can affect the absorption of the insulin. (A and D) are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure good serum glucose control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin.

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A.Advise the client that food from the meal tray should not be shared with others. B.Leave the room and discuss the incident privately with the staff member. C.Objectively document the situation as observed on a variance report. D.Call the nurse-manager to the client's room immediately.

B Discussing the incident privately (B) promotes open communication between the charge nurse and staff member. The client is free to share unwanted food (A) with family or friends, but the employee should not ask for the client's food. (C) is not necessary, and the charge nurse can respond to this situation without implementing (D).

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A.Diabetes insipidus B.Hypotension C.Hyperkalemia D.Uremia

B During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension (B). (A) is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not (C). (D) is characteristic of chronic renal failure with multiple body system involvement.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? A.Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B.Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C.Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D.Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

B Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients (B). (A) is too authoritarian and does not permit education to play a role in reducing fears. (C) is likely to be intrusive to the family member. Arbitrary staffing (D) without education does not reduce staff fears, even with the provision of peer counseling.

The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had a appendectomy. The IV tubing being using delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.) A.15 B.32 C.64 D.50

B Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min

The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A.Tachypnea B.Guaiac-positive stool C.Multiple small abdominal bruises D.Dependent pitting edema

B Fragmin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding, such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed. (A) is not an indication to hold the medication unless accompanied by signs of bleeding. (C) is an expected result. (D) is related to fluid volume, rather than anticoagulant therapy.

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A."It sounds like you're feeling very sad." B."Tell me more about how you're feeling." C."How often do you have crying spells?" D."Do you want to talk about these feelings?"

B It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings (B). (A) is a leading response, and the client may not be feeling sad. (C and D) are close-ended questions that do not facilitate communication.

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? A.Sexual intercourse with the spouse occurs four times a week. B.The spouse has never seen the client naked. C.The client has had surgery for permanent birth control. D.A history of a 20-lb weight loss occurred in the past year.

B It is usual for spouses to see each other without clothing, so a follow-up question about (B) should provide additional information about the client's self-concept and body image. (A and C) are choices within the continuum of normal and acceptable sexual needs based on each couple's preferences. Body image is a perception of one's physical self and weight gain or loss normally affects one's self-image (D).

The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 pounds. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 ml. Which is the correct dosage indicated on the image? A.30ml B.15ml C.10ml D.5ml

B Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL

When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A.Ascending numbness from the feet to the knees B.Decrease in cognitive status of the client C.Blurred vision and sensation changesD. Persistent unilateral headache

B Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately (B). (A, C, and D) are findings associated with Guillain-Barré syndrome that should also be reported, but are not as critical as the client's hypoxic status.

When caring for a client in labor, which finding is most important to report to the primary health care provider? A.Maternal heart rate, 90 beats/min. B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal temperature, 100.0° F

B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman in labor.

The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? A.High level of anxiety present B.History of previous suicide attempt C.Family history of depression D.Self-care deficit is noted

B Rationale: A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan (B). The others (A, C, and D) may also be risk factors but are not as significant as a history of previous attempts.

A nurse is assessing a client with heart failure who has been prescribed digoxin (Lanoxin) for therapy. Which finding indicates an issue with the medication management? A.Regular heart rate of 88 beats/min B.Serum potassium level, 2.9 mEq/L C.Weight decreases by 1 lb daily D.Serum sodium level, 138 mEq/L

B Rationale: A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low (B). (A, C, and D) are all expected findings when caring for a client with congestive heart failure.

A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? A.Administer an antianxiety medication PRN. B.Assess the client's vital signs. C.Notify the primary health care provider. D.Determine coping mechanisms used in the past.

B Rationale: Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the patient and rule out physiologic causes (B). Nonpharmacologic measures should be taken first (A). (C and D) may be considered but are not as high priority as the initial physiologic assessment.

The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A.Ammonia odor is noted when the catheter is emptied. B.240 mL of urinary output is produced in 12 hours. C.A 16-French catheter was used for an adult female. D.Drainage system is hanging below the level of the bladder.

B Rationale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14- to 18-French catheters are common sizes used in the adult female (C). Below the level of the bladder is the correct position for the drainage bag (D).

Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? A.Auscultation of vesicular breath sounds B.Pulse oximetry reading of 89% C.Arterial Pao2 of 86% D.Resonance on percussion of the lungs

B Rationale: An oxygen saturation lower than 90% indicates hypoxia (B). (A, C, and D) are all normal findings.

A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? A.Two-month-old who is unable to roll from back to abdomen B.Ten-month-old who cannot sit without support C.Nine-month-old who cries when his mother leaves the room D.Eight-month-old who has not yet begun to speak words

B Rationale: As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).

When blood or blood products are administered, which task can be assigned to the licensed practical nurse (LPN)? A.Initiation of the blood product B.Obtaining vital signs after infusion has begun C.Assessment of client's condition prior to blood administration D.Evaluation of client's response after receiving blood product

B Rationale: Blood and blood products must be initiated by the registered nurse (RN) (B); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. (A, C, and D) are all part of the nursing process and the scope of the RN.

The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance? A.Any time the client awakens during the night B.Whenever the client has feelings of dizziness C.Right after meals if insulin is not administered 30 minutes before the meal D.Only at scheduled times; additional testing harmful to fingertips

B Rationale: Clients should be instructed to always check their blood glucose level whenever they feel faint or dizzy (B). There is great variability in recommendations for the frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, and then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test four times a day or as little as once each week, depending on the consistency of their diet and exercise and stability of their blood sugar level. (A, C, and D) provide inaccurate information.

A client with non-Hodgkin's lymphoma has been prescribed cyclophosphamide (Cytoxan) IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? A.Sores on the mouth or tongue B.Chills, fever, and sore throat C.Loss of appetite or weight with diarrhea D.Changes in color of fingernails or toenails

B Rationale: Cyclophosphamide (Cytoxan) is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately (B). These are expected signs and symptoms of non-Hodgkin's lymphoma (A and C). (D) is a normal side effect of cyclophosphamide.

The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? A.Administer epinephrine. B.Defibrillate immediately. C.Bolus with isotonic fluid. D.Notify the health care provider.

B Rationale: Defibrillation is the first and most effective emergency treatment for ventricular fibrillation (B). The others may follow the first action (A, C, and D).

A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? A.Insert a large-bore IV for fluid resuscitation. B.Prepare to assist with maintaining the airway. C.Cleanse the wounds using sterile technique. D.Administer an analgesic for pain.

B Rationale: High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care (B). (A, C, and D) are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway.

A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates that the patient is at risk for toxicity? A.Deep tendon reflexes—decrease to 2+ B.100 mL of urine output in 4 hours C.Respiratory rate decreases to 16 breaths/min D.Serum magnesium level, 7.5 mg/dL

B Rationale: Magnesium sulfate, a central nervous system (CNS) depressant, helps prevent seizures, so (A) is a positive sign that the medication is having a desired effect. The minimum urine output expected for a repeat dose of magnesium sulfate is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor excretion of magnesium, with a possible cumulative effect (B). A decreased respiratory rate (C) indicates that the drug is effective. A respiratory rate below 12 breaths/min indicates toxic effects. The therapeutic level of magnesium sulfate for a PIH client is 4 to 8 mg/dL (D).

When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L

B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).

The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to change a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen.

B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.

The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is less than 2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? A.Assessment B.Planning C.Implementation D.Evaluation

B Rationale: Planning (B) allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are part of the care for the client but are not the appropriate actions for formulating the expected outcome (A, C, and D).

The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees

B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).

The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A.9:30 am B.10:30 am C.12:00 pm D.3:00 pm

B Rationale: Regular insulin is short-acting and peaks between 2 and 3 hours after administration (B). The client is most at risk for a hypoglycemic reaction during the peak times. (A, C, and D) are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.

The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? A.Social Security Act of 1990 B.American with Disabilities Act of 1990 C.Medicaid Act of 1965 D.Mental Health Act of 1946

B Rationale: The Americans with Disabilities Act (B) guarantees the client the right to participate in treatment planning. (A) is a federal insurance program that provides benefits to retired persons, the unemployed, and the disabled. (C) is a program for eligible individuals and/or families with low income and resources. (D) provides for public education regarding psychiatric illnesses.

A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition? A.Levofloxacin (Levaquin) B.Acyclovir sodium (Zovirax) C.Fluconazole (Diflucan) D.Esomeprazole (Nexium)

B Rationale: The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or shingles (B). Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client (A). Fluconazole is an antifungal and is used to treat candidiasis in the HIV client (C). Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease (D).

Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A.Limit fluids to prevent infection to the surgical site. B.Place the infant in the prone position. C.Provide a low-residue diet to limit bowel movements. D.Cover sac with a moist sterile dressing.

B Rationale: The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum (B). Fluids should be increased postoperatively to prevent dehydration (A). A high-fiber diet should be implemented to prevent constipation (C). After the repair, the sac is no longer exposed, so (D) does not apply.

When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A.Teach the family about signs and symptoms of hypoxia. B.Take the vital signs and obtain an O2 saturation level. C.Evaluate the need for tracheal suctioning. D.Revise the plan of care to include tracheostomy care.

B Rationale: The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data (B). (A, C, and D) are all part of the nursing process and should not be delegated under the nurse's scope of practice.

A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, which intervention is best for the nurse to implement? A.Explain that harm to the fetus is highly unlikely. B.Answer all their questions regarding the procedure. C.Encourage them to verbalize their feelings. D.Show them a video about the procedure.

B Rationale: The nurse should allay their concerns by providing information about the procedure and answering questions (B). This action assists the couple in coping with the situation. (A) may offer false reassurance. (C) alone does not resolve the couple's fears. Although (D) may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely to be most helpful in calming their fears.

A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24/breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first? A.Administer a PRN dose of a prescribed analgesic. B.Assess the incision for any drainage or redness C.Instruct the UAP to take vital signs hourly. D.Assist the client to a more comfortable position.

B Rationale: The nurse's priority is to observe for possible hemorrhage (B). The client is at high risk for hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the blood pressure may be stable or increase slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client should then be assessed for the need of an analgesic (A, C, and D) should be implemented.

The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A.Administer regular insulin IV. B.Start an IV infusion of normal saline. C.Check serum electrolyte levels. D.Give a potassium supplement.

B Rationale: The patient in DKA experiences severe dehydration and must be rehydrated before insulin is administered (B). The other actions will follow rehydration (A, C, and D).

The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick.

B Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).

The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? A.Surgical mask, clean gloves, and gown B.Properly fitted N95 respirator or mask C.Sterile gloves and gown D.Goggles, clean gloves, and gown

B Rationale: The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask (B). (A, C and D) do not provide the appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions.

The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. A. Drop prescribed number of drops into conjunctival sac. B. Wash hands and apply clean gloves. C. Place dominant hand on the client's forehead. D. Ask the client to close the eye gently. A. C, B, A, D B. B, C, A, D C. A, B, D, C D. A, C, B, D

B Rationale: Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (B). Placing the dominant hand on the client's forehead (C) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (A); asking the client to close the eye gently helps distribute the medication (D).

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A.3+ protein in the urine B.Blood urea nitrogen >25 mg/dL C.Blood pH >7.45 D.Urine output, 2500 mL/day

B Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." D. "Would you like to make a change in his pharmacologic regimen?" A. C, B, A, D B. B, C, A, D C. A, B, C, D D. A, C, D, B

B SBAR: S = Situation and includes introduction of the nurse and client/setting (B). B = Background and includes the presenting complaint and relevant history (C). A = Assessment and includes current vital signs and other information (A). R = Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (D).

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A.Hearing acuity B.Immunization history C.Weight and length D.Head circumference

B The Centers for Disease Control and Prevention indicate that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups (B) is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases. Assessment of (A, C, and D) provides valuable information but does not supply information about infants' susceptibilities to vaccine-preventable diseases, which are major causes of infant mortality and morbidity.

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A.Assess skeletal pins for infection. B.Assist the client with toileting. C.Establish thrombus prevention care. D.Evaluate pain management plan.

B The PN can implement nursing care, such as (B). The PN assists the RN in the development of a teaching plan and reinforces information to the client according to the plan. (A, C, and D) are outside the scope of PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing to the plan of care under the supervision of the RN.

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A.Keep the residual limb elevated during positioning. B.Instruct the client to grasp the overhead trapeze bar. C.Maintain alignment with an abduction pillow. D.Use pillow support to prevent turning to a prone position.

B The client will gain upper body strength and independence by using the overhead trapeze bar for positioning (B). Elevation of the residual limb is controversial (A) because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. (C) is used for alignment following some hip surgeries. A prone position (D) should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A."I will avoid coughing, sneezing, and forceful nose blowing." B."Swimming can begin on the tenth postoperative day." C."Any mild discomfort can be managed with acetaminophen." D."Drainage from my ears is expected after the surgery."

B The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D) reflect correct responses.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? A.Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B.Assess the client for pain and administer pain medication as prescribed. C.Encourage the client to take short shallow breaths for 5 minutes. D.Prepare to administer sodium bicarbonate IV over 30 minutes.

B These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? A.42 B.83 C.125 D.250

B Use the following calculation (B): 20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min

A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A.This feeling occurs during feeding with a breast infection. B.This sensation occurs as breast milk moves to the nipple. C.The baby does not have good latch-on. D.The infant is not positioned correctly.

B When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.

Genetic testing is being discussed with a couple at the fertility clinic. What is the nurse's best response when they express concerns? A) "You should be tested because it will be to your benefit." B) "Environmental factors can have an impact on genetic factors." C) "This type of testing will determine if you'll need in vitro fertilization." D) "If you have a gene for a disease there is a probability that your children will inherit it."

B) "Environmental factors can have an impact on genetic factors."

A client with schizophrenia, paranoid type, is readmitted involuntarily to the hospital because family members state that he has threatened to harm them physically. When exploring feelings about the readmission, the client angrily shouts, "You're one of them. Leave me alone!" How should the nurse respond? A) "Try not to be afraid. I will not hurt you." B) "I can see you are upset. We can talk more later." C) "I am not one of them, and I am here to help you." D) "Your family and the staff are trying to help you."

B) "I can see you are upset. We can talk more later."

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond? A) "I'm so sorry, but I need to see other clients." B) "I have to go now, but I will come back in 10 minutes." C) "You'll be able to rest after the medicine starts working." D) "You'll feel better after I've made you more comfortable."

B) "I have to go now, but I will come back in 10 minutes." - The response "I have to go now, but I will come back in 10 minutes" demonstrates that the nurse cares about the client and will have time for the client's special emotional needs. This approach allays anxiety and reduces emotional stress. Saying "I'm so sorry, but I need to see other clients" indicates that the nurse's other tasks are more important than the client's needs. Telling the client "you'll be able to rest after the medicine starts working" is false reassurance and not therapeutic. Saying "you'll feel better after I've made you more comfortable" does not respond to the client's need and cuts off communication.

A client on a psychiatric unit who has been hearing vices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make? A) "You have to take your medicine." B) "Your doctor wants you to have this medicine. Swallow it." C) "There must be a reason why you don't want to take your medicine." D) "This is the medication that your doctor ordered for you to make you well."

B) "Your doctor wants you to have this medicine. Swallow it."

The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? A) 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os. B) 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. C) 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP. D) 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.

B) 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. - Considering acuity level, it is best for the nurse to assign 10 clients to each of the PNs, have the UAP take vial signs and collect I&Os and the charge nurse care for the new admissions since they will all require assessment by the RN (B). The charge nurse should take admissions (A). The UAP is not qualified to conduct an admission assessment (C). The UAP, even with 10 years experience, is not qualified to take responsibility for total care of clients (D).

A client with cellulitis is recovering at home after experiencing a severe reaction to a new prescription for ampicillin (Unisyn) that was administered by a home health nurse. The client's allergies to penicillin and sulfonamide are noted in all critical areas of the home health record. What consequence can occur based on the nurse's action? A) None since the action did not result in the client's wrongful death. B) A malpractice suit based on lack of reasonable and prudent care. C) Disciplinary action initiated by the state's nurse licensing board. D) An intentional tort based on failure to note the client's allergies.

B) A malpractice suit based on lack of reasonable and prudent care. - Medication errors involving failure to provide reasonable and prudent care, including improper documentation of medication administration, failure to recognize side effects or contraindications, and negligence in verifying a client's allergies, may result in a malpractice suit against the nurse (B). (A) does not take into account the client's documented allergies and reaction. Actions of discipline by licensing agencies (C) focus on repeated incompetent practice or substance abuse, not single error occurrences. An intentional tort (D) is a civil wrong made against a person that willfully violates another's rights, such as assault, battery, and/or false imprisonment.

A client is scheduled for emergency abdominal surgery. What is the priority preoperative nursing objective when caring for this client? A) Recording accurate vital signs B) Alleviating the client's anxiety C) Teaching about early ambulation D) Maintaining the client's nutritional status

B) Alleviating the client's anxiety

A client is in the ICU after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? Select all that apply. A) Minimizing environmental stimuli B) Assessing for respiratory complications C) Monitoring and maintaining blood pressure D) Initiating a bowel and bladder training program E) Discussing long-term treatment plans with the family

B) Assessing for respiratory complications C) Monitoring and maintaining blood pressure

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? A) Analysis B) Assessment C) Nursing interventions D) Proposed nursing care

B) Assessment

A client is receiving pyridostigmine bromide (Mestinon) to control the symptoms of myasthenia gravis. Which client behavior would indicate that the drug therapy is effective?A) Decreased oral secretions B) Clear speech C) Diminished hand tremors D) Increased ptosis

B) Clear speech - Clear speech (B) is the result of increased muscle strength. Muscle weakness characteristic of myasthenia gravis often first appears in the muscles of the neck and face. (A and D) are symptoms of multiple sclerosis that would persist if the medication was ineffective. Hand tremors (C) are not typical symptoms of the disease.

The nurse is teaching a client with cancer about opioid management for intractable pain and tolerance related side effects. The nurse should prepare the client for which side effect that is most likely to persist during long-term use of opioids? A) Sedation. B) Constipation. C) Urinary retention. D) Respiratory depression.

B) Constipation. - The client should be prepared to implement measures for constipation (B) which is the most likely persistent side effect related to opioid use. Tolerance to opiate narcotics is common, and the client may experience less sedation (A) and respiratory depression (D) as analgesic use continues. Opioids increase the tone in the urinary bladder sphincter, which causes retention (C) but may subside.

A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? A) Weight loss. B) Dizziness. C) Muscle cramps. D) Dry mucous membranes.

B) Dizziness. - Angiotensin-converting enzyme (ACE) inhibitors are used in CHF to reduce afterload by reversing vasoconstriction common in heart failure. This vasodilation can cause hypotension and resultant dizziness (B). (A) is desired if fluid overload is present, and may occur as the result of effective combination drug therapy such as diuretics with ACE inhibitors. (C) often indicates hypokalemia in the client receiving diuretics. Excessive diuretic administration may result in fluid volume deficit, manifested by symptoms such as (D).

What type of interview is most appropriate when the nurse admits a client to the clinic? A) Directive B) Exploratory C) Problem solving D) Information giving

B) Exploratory

A 15-year-old adolescent tells the school nurse, "I have persistent pain during my periods." What should the nurse encourage her to do? A) Continue daily activities B) Have a gynecologic exam C) Eat a nutritious diet containing iron D) Practice relaxation of the abdominal muscles

B) Have a gynecologic exam

A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem notifies the nurse to notify the HCP? A) Excessive carbohydrate intake B) Lack of protein supplementation C) Insufficient intake of water-soluable vitamins D) Increased concentration of electrolytes in cells

B) Lack of protein supplementation

In today's health care delivery system, a nurse as a teacher is confronted with multiple stressors. What is the major stressor that detracts from the effectiveness of the teaching effort? A) Extent of informed consumerism B) Limited time to engage in teaching C) Variety of cultural beliefs that exist D) Deficient motivation in adult learners

B) Limited time to engage in teaching

A 19-year-old male client who has sustained a severe head injury is intubated and placed on assisted mechanical ventilation. To facilitate optimal ventilation and prevent the client from "fighting" the ventilator, the health care provider administers pancuronium bromide (Pavulon) IV, with adjunctive opioid analgesia. What medication should the nurse maintain at the client's bedside? A) Dantrolene sodium (Dantrium) B) Neostigmine bromide (Prostigmin) C) Succinylcholine bromide (Anectine) D) Epinephrine (Adrenalin)

B) Neostigmine bromide (Prostigmin) - Neostigmine bromide (Prostigmin) (B) and atropine sulfate (Atropine), both anticholinergic drugs, reverse the respiratory muscle paralysis caused by pancuronium bromide. (A, C, and D) are not antagonists to pancuronium bromide and would not be helpful in reversing the effects of the drug compared with the use of anticholinergics.

A nurse is caring for a client in albor. What client response indicates that the transition phase of labor probably has begun? A) Assume the lithotomy position B) Perspires that he has a flushed face C) Indicates back and perineal pain D) Exhibits decrease in frequency of contractions

B) Perspires that he has a flushed face

A newborn is admitted to the NICU with a myelomeningocele. What is the priority nursing intervention during the first 24 hours? A) Using only disposable diapers B) Place the infant prone or in a side-lying position C) Wash the infant's genital area with an anti infective

B) Place the infant prone or in a side-lying position - Placing the infant prone or in a side-lying position decreases pressure on the sac.

The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? A) Building model airplanes. B) Playing follow-the-leader. C) Stringing large and small beads. D) Playing with Playdough and clay.

B) Playing follow-the-leader. - School-aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school-aged children enjoy crafts, (C and D) are more appropriate for pre-school children.

A nurse is caring for a male client who is scheduled for dilation of the urethra. Which structure surrounding the male urethra should the nurse include in the teaching when explaining the procedure? A) Epididymis B) Prostate gland C) Seminal vesicle D) Bulbourethral gland

B) Prostate gland

The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? A) To promote maternal production with neonatal demand, pump only the volume the newborn takes. B) Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. C) Pump every 2 to 3 hours, including during the night, to increase breast milk volume. D) A glass of wine prior to pumping reduces anxiety and increases breast milk production.

B) Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. - Breast milk, rather than formula, provides antibodies and nutrition that is easily digested and readily absorbed by an immature newborn (B). Breast milk can be frozen and used if the mother is unable to provide breast milk every day, so (A) is not necessary. The mother does not have to pump through the night (C). Alcohol is excreted in breast milk and is not safe for the newborn (D).

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A) Low-residue, bland diet B) Small, frequent feeding schedule C) Fluid intake less than half a quart D) Low-protein, high-carbohydrate diet

B) Small, frequent feeding schedule

A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD)? A) Perforation of the uterus B) Spontaneous device expulsion C) Discomfort associated with coitus D) Development of vaginal infections

B) Spontaneous device expulsion

The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A) Administer regular insulin IV B) Start an IV infusion of NS C) Check serum electrolyte levels D) Give a potassium supplement

B) Start an IV infusion of NS - The patient in DKA experiences severe dehydration and must be rehydrated before insulin is administered (B). The other actions will follow rehydration (A, C, and D).

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A) The cuff wraps around the girth of the leg. B) The UAP auscultates the popliteal pulse with the cuff on the lower leg. C) The client is placed in a prone position. D) The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

B) The UAP auscultates the popliteal pulse with the cuff on the lower leg. - When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an accurate assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.

The nurse is reviewing the use of the patient-controlled analgesia (PCA) pump with a client in the immediate postoperative period. The client will receive morphine 1 mg IV per hour basal rate with 1 mg IV every 15 minutes per PCA to total 5 mg IV maximally per hour. What assessment has the highest priority before initiating the PCA pump? A) The expiration date on the morphine syringe in the pump. B) The rate and depth of the client's respirations. C) The type of anesthesia used during the surgical procedure. D) The client's subjective and objective signs of pain.

B) The rate and depth of the client's respirations. - A life-threatening side effect of intravenous administration of morphine sulfate, an opiate narcotic, is respiratory depression (B). The PCA pump should be stopped and the healthcare provider notified if the client's respiratory rate falls below 12 breaths per minute, and the nurse should anticipate adjustments in the client's dosage before the PCA pump is restarted. (A, C, and D) provide helpful information, but are not as high a priority as the assessment described in (B).

The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? A) An RN should be assigned to take temperatures frequently. B) Tympanic and oral temperatures are equally accurate. C) The PN should take rectal temperatures on this child. D) The pediatrician should decide how to assess the temperature.

B) Tympanic and oral temperatures are equally accurate. - A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies (B). The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the child's temperature, but must assess readings received from assistive personnel (A). Although rectal readings are highly accurate (C), such an invasive procedure is unnecessary. (D) is not required.

Which instruction(s) should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A.Keep the medication in your pocket so that it can be accessed quickly. B.Call 911 if chest pain is not relieved after one nitroglycerin. C.Store the medication in its original container and protect it from light. D.Activate the emergency medical system after three doses of medication. E.Do not use within 1 hour of taking sildenafil citrate (Viagra).

B,C Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E).

The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.) A.Salt-free diet B.Quiet environment C.Deep tendon reflex assessments D.Neurologic checks E.Daily weights

B,C,D,E Rationale: Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic changes when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload. (A) would contribute to dilutional hyponatremia.

Which intervention(s) should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) A.Maintain bed rest for the first 6 hours after delivery. B.Palpate and massage the fundus to maintain firmness. C.Have client empty bladder if fundus is above umbilicus. D.Check perineal pad for color and consistency of lochia. E.Apply ice pack or witch hazel compresses to the perineum.

B,D,E Rationale: The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C).

A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

B. Explain that this normal secretion can be assessed at the next visit

The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A.Reports feelings of sadness B.Mood changes from depressed to happy C.Begins giving away possessions D.Becomes compliant with medication regimen E.Independently joins a support group

BC Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide (B and C). Feelings of sadness are signs of depression but not impending suicide (A). (D and E) are not typically indicative of impending suicide.

475. During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)

Background Assessment Recommendation

18. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Bagel with jelly and skim milk

49. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Baked apples topped with dried raisins

50. When caring for a client on a ventilator, which finding provides the greatest indication that the client has an open airway? a) The client has asymmetrical chest expansion b) Bilateral breath sounds can be auscultated c) The client has been turned q2h. d) Prescribed ventilator settings are being maintained

Bilateral breath sounds can be auscultated

Which complication is a patient with cirrhosis at risk for?

Bleeding

84. Hand washing is the most important intervention aimed at reducing the spread of infection in the hospitalized population. What mechanism describes the effect that hand washing has upon the chain of infection? a) Destroys non-human reservoir b) Blocks a portal of entry c) Reduces victim's susceptibility d) Blocks pathogen transmission

Blocks pathogen transmission

123. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? a) Corticosteroids b) Bronchodilators c) Beta blockers d) Beta-adrenergics

Bronchodilators

582. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering?

Bronchodilators

Duodenal ulcer ss ▪

Burning pain occurs in the midepigastric area 1.5 to 3 hours after a meal and during the night (often awakens the client). ▪ Melena is more common than hematemesis.▪ Pain is often relieved by the ingestion of food. Symptoms common to all types of ulcers include: belching Bloating

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A.A client with an admitting diagnosis of menorrhagia who is now 24 hours post-vaginal hysterectomy B.A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C.A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D.A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

C (C) requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one on one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic and careful assessment is essential. (A, B, and D) could all be cared for by a PN under the supervision of the RN.

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A.Encourage the client to turn from side to side every 2 hours. B.Elevate the foot of the client's bed at least 6 inches. C.Encourage the client to ambulate every 3 hours. D.Teach the client how to perform leg exercises while in bed.

C Ambulation is the best way to increase peripheral vascular activity (C). (A, B, and D) will increase peripheral vascular activity but are not as effective as ambulation.

A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A.Pain scale B.Vital signs C.Breath sounds D.Level of consciousness

C Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds (C). (A, B, and D) are important assessment data but are not specifically related to insertion of a central venous catheter.

Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart? A.Stand on a line drawn 10 feet from the chart. B.Read each sentence slowly and carefully. C.Cover one eye while reading the chart with the other. D.Begin by identifying the first line that is hard to read.

C Each eye should be tested separately (C) because visual acuity can vary from one eye to the other. A Snellen chart scores vision in comparison with what a person with normal vision can read at a distance of 20 feet (A). The Snellen chart is comprised of letters, not sentences (B). The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read (D)

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A.Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B.Apply ice packs to edematous or tender joints to reduce pain and swelling. C.Warm the child with an electric blanket prior to getting the child out of bed. D.Immobilize swollen joints during acute exacerbations until function returns.

C Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. (A) on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness (B). (D) is contraindicated, because joints should be exercised, not immobilized.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. A. Gently insert the catheter without suction using sterile technique. B. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). C. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. D. Apply suction intermittently while withdrawing the catheter. A. B, C, A, D B. A, C, B, D C. C, B, A, D D. D, C, B, A

C Equipment should be set up and adjusted prior to beginning the procedure (C). Hyperoxygenation using an MRB should be completed prior to inserting the catheter (B). After preoxygenation, the catheter can be inserted (A) and suction can be applied intermittently (D).

The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A.Parents of children with spina bifida B.High school girls in a health class C.Individuals interested in having children D.Postpartum women attending a baby care class

C Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is (C). Parents with children who already have a neural tube defect such as spina bifida (A) are not as invested in the content as (C). High school age students (B) may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than (C). (D) may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A.Allow the client to discuss the seriousness of the illness. B.Ensure that the client is provided with information about medications. C.Encourage as much independence in decision making as possible. D.Include the client in planning the course of treatment.

C Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible (C) helps reduce stress experienced with repeated hospitalization. (A, B, and D) are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand (B) and participate (D) in the hospitalized plan of care.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A.Serum digoxin level is 1.5 ng/mL B.Blood pressure is 104/68 mm Hg C.Serum potassium level is 2.5 mEq/L D.Apical pulse is 68/min

C Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A.Perform a digital evaluation for fecal impaction. B.Administer a PRN dose of psyllium (Metamucil). C.Obtain a stool specimen for culture and sensitivity. D.Instruct the UAP to obtain incontinent pads for the client.

C Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen (C). Impaction is unlikely, so (A) is of less priority and may not be necessary. (B) is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort (D) are important interventions but of less priority than determining the cause of the client's diarrhea.

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A.Inspection of the skin B.Breath sound auscultation C.Pain scale measurement D.Mobility limitations

C Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority (C). (A, B, and D) are part of the complete assessment but do not have the priority of (C) for this client.

Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client with oral candidiasis, has been effective? A.The client denies dysphagia. B.The client is afebrile with warm and dry skin. C.The oral mucosa is pink and intact. D.There is no reflux following food intake.

C Mycostatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx (C). The ability to swallow (A) does not indicate that the medication has been effective. (B and D) do not reflect effectiveness of the local medication.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A.Hyperexcitability of reflexes B.Hyperextension of the head and back C.Inability to flex the chin to the chest D.Lateral facial paralysis

C Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve.

A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A.Administer oxygen per nasal cannula at 2 L/min. B.Plan to check his vital signs again in 30 minutes. C.Notify the health care provider of the change in mental status. D.Ask the client why he thinks there are bugs in the bed.

C One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status (C). It is important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not the top priority. Vital signs should be monitored frequently (B), but the client's confusion should be reported immediately. (D) is not a useful intervention.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A.Teach the client testicular self-examination (TSE). B.Assess for the presence of blood in the urine. C.Ask about scrotal pain or blood in the semen. D.Inquire about a history of kidney stones.

C Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine.

The nurse should encourage a laboring client to begin pushing at which point? A.When the cervix is completely effaced B.When the client describes the need to have a bowel movement C.When the cervix is completely dilated D.When the anterior or posterior lip of the cervix is palpable

C Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm (C). If pushing begins before the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson's reflex).

Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? A.The client reports a continuous feeling of needing to void. B.Urinary drainage is pink 24 hours after surgery. C.The hemoglobin level is 8.4 g/dL 3 days postoperatively. D.Sterile saline is being used for bladder irrigation.

C Rationale: A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage (C). The others are all expected findings after a TURP (A, B, and D).

Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis? A.Administer stool softeners. B.Place the client on fluid restriction. C.Provide a low-residue diet. D.Add a milk product to each meal.

C Rationale: A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.

The nurse prepares to administer digoxin (Lanoxin), 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? A.Discontinue the digoxin. B.Notify health care provider. C.Administer the digoxin. D.Reverify the digoxin level.

C Rationale: A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should be continued to maintain a therapeutic range (C). The others actions are not indicated for a therapeutic range (A, B, and D).

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? A.Claustrophobia B.Acrophobia C.Agoraphobia D.Necrophobia

C Rationale: Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety.

An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? A.Long-acting medication is more effective than daily medication. B.A client with substance abuse must not take any oral medications. C.There will continue to be a risk of alcohol and drug interaction. D.Support groups are only helpful for substance abuse treatment.

C Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect information.

While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? A.Transfer the call into the room of the client. B.Instruct the secretary to explain reason for the call. C.Ask another nurse to take the phone call. D.Ask the health care provider to see the client on the unit.

C Rationale: Another nurse should be asked to take the phone call (C), which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. (A and B) should not be done during an acute change in the client's condition. Requesting the health care provider (D) to come to the unit is premature until the nurse completes assessment of the client's status.

The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? A.Uses descriptive words such as "gurgling" to describe breath sounds B.Records temperature 30 minutes before and after giving acetaminophen C.Charts some actions in advance of performing them D.Includes the client's response to an intervention

C Rationale: Charting actions prior to implementing them is an example of fraudulent charting and the graduate nurse should receive further education (C). (A, B, and D) are appropriate charting examples.

When caring for a hospitalized child with type 1 diabetes mellitus, which intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? A.Teach the signs and symptoms of hypoglycemia. B.Assess for polydipsia, polyphasia, and polyuria. C.Check the blood glucose level every 4 hours. D.Evaluate the need for a snack between meals.

C Rationale: Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances (C). Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP (A, B, and D).

A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client? A.CAGE questionnaire for alcoholism B.Addiction Severity Index C.Glasgow Coma Scale D.DSM multiaxial evaluation

C Rationale: Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale (C), has the highest priority. (A) is useful in helping clients recognize their alcoholism. (B and D) are comprehensive assessments that should be completed after the acute phase is resolved.

A 12-year-old boy complains to the nurse that he is "short" (4'5" [53 inches]). His twin sister is 5 inches taller than he is (4'10" [58 inches]). Based on these findings, what conclusion should the nurse reach? A.The boy is not growing as normally expected. B.The girl is experiencing a period of unexpected growth. C.A normal growth spurt occurs in girls 1 to 2 years earlier than boys. D.Male-female twins are not identical; therefore, their growth cannot be compared.

C Rationale: Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female (D).

A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A.Fever, elevated white blood count, elevated platelets B.Fatigue, weight loss and anorexia, elevated red blood cells C.Hyperplasia of the gums, elevated white blood count, weakness D.Hypocellular bone marrow aspirate, fever, decreased hemoglobin level

C Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia.

The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which of the following is most important to report to the primary health care provider? A.Takes medication with milk B.Blood pressure, 104/64 mm Hg C.Elevated liver enzyme levels D.Hemoglobin level, 13 g/dL

C Rationale: Indomethacin is an antiinflammatory drug and can cause liver damage. Elevated liver enzyme levels indicate a complication with the drug (C). This medication should be taken with food or milk to reduce gastrointestinal (GI) side effects (A). (B and D) are normal findings.

When administering an intramuscular injection, which factor is most important to ensure the best medication absorption? A.Compress the syringe plunger quickly. B.Select a small-gauge needle. C.Inject the needle at a 90-degree angle. D.Select a small-diameter syringe.

C Rationale: Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle so that appropriate absorption can occur (C). Too rapid injection of the medication (A) may be painful and may cause medication leakage and reduced absorption. (B) will reduce injection discomfort but will not affect absorption. A syringe barrel that is too small (D) increases the pressure during the injection and may traumatize tissue without improving medication absorption.

A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement? A.Orient the client to activities on the unit. B.Document suicide precautions on the shift report. C.Assign the client to a semiprivate room. D.Obtain a verbal no-suicide contract with the client.

C Rationale: It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room (C). (A) does not have the priority of (C). (B and D) can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation.

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.Draw arterial blood gases. B.Notify the primary health care provider. C.Position in a high Fowler's position with the legs down. D.Obtain a chest X-ray.

C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).

Which disaster management intervention by the nurse is an example of primary prevention? A.Emergency department triage B.Follow-up care for psychological problems C.Education of rescue workers in first aid D.Treatment of clients who are injured

C Rationale: Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury (C). (A) is an example of secondary prevention. (B) is an example of tertiary prevention. (D) is an example of secondary prevention.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A.The apical heart rate is 64 beats/min. B.The serum digoxin level is 1.5 ng/mL. C.The client reports seeing yellow-green halos. D.The potassium level is 4.0 mEq/L.

C Rationale: Reports of yellow-green halos and blurred vision are a sign of digoxin toxicity (C). The others are normal findings (A, B, and C).

When assessing the laboratory findings of a 38-year-old client with tuberculosis who is taking rifampin (Rifadin), which laboratory finding would be most important to report to the primary health care provider immediately? A.Orange-colored urine B.Potassium level, 4.9 mEq/L C.Elevated liver enzyme levels D.Blood urea nitrogen (BUN) level, 12 mg/dL

C Rationale: Rifampin can cause hepatoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider (C). Orange discoloration of the urine is an expected side effect of this medication (A). The potassium level (B) is normal. A BUN level of 12 mg/dL is within defined parameters (D).

A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? A."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." B."You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." C."For your safety and well-being, it may be necessary to share some of our conversations with the health care team." D."I am legally required to document all of our conversations in the electronic medical record."

C Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client (D).

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A.Client will not demonstrate cross addiction. B.Codependent behaviors will be decreased. C.Excessive CNS stimulation will be reduced. D.The client will demonstrate an increased level of consciousness.

C Rationale: Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described but do not have the priority of (C).

Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider? A.Nervousness B.Increased appetite C.Apical heart rate of 130 beats/min D.Insomnia

C Rationale: The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders (C). (A, B, and D) are all expected findings that should also be reported but are not as critical.

Which vital sign in a pediatric client is most important to report to the primary health care provider? A.Newborn with a heart rate of 140 beats/min B.Three-year-old with a respiratory rate of 28 breaths/min C.Six-year-old with a heart rate of 130 beats/min D.Twelve-year-old with a respiratory rate of 16 breaths/min

C Rationale: The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min (C). The others are all within normal range for those ages (A, B, and D).

The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? A.Potassium level, 3.9 mEq/dL B.Creatinine level,1.1 mg/dL C.Sodium level, 125 mEq/L D.Calcium level, 9 mg/dL

C Rationale: The normal serum sodium level is 135 to 145 mEq/L (C). This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. (A, B, and D) are all within normal parameters.

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? A.Stage I B.Stage II C.Stage III D.Stage IV

C Rationale: The statement above describes a stage III ulcer which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle (C). A stage I ulcer includes intact skin with nonblanchable redness of a localized area (A). A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed (B). Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer (D).

The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? A.Fine crackles B.Wheezes C.Course crackles D.Stridor

C Rationale: This sound is caused by air passing through airways that are intermittently occluded by mucus (C). Fine crackles are a series of short-duration, discontinuous, high-pitched sounds (A). Wheezes are continuous, high-pitched, musical or squeaking-type sounds (B). Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway (D).

Which of the following cardiac rhythms is represented in the image? A.Normal sinus rhythm B.Sinus tachycardia C.Ventricular fibrillation D.Atrial fibrillation

C Rationale: Ventricular fibrillation (C) is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. (A, B, and D) are not represented in the image.

Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A.States having difficulty with color perception B.Presents with opacity of the lens upon assessment C.Complains of seeing a cobweb-type structure in the visual field D.Reports the need to use a magnifying glass to see small print

C Rationale: Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss (D) are expected signs and symptom of cataracts, but do not need immediate attention.

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? A.Perform range-of-motion exercises on the lower extremities every 4 hours. B.Place a small firm pillow under the upper back to flex the lumbar spine gently. C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D.Position in reverse Trendelenburg with the feet firmly against the foot of the bed.

C Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles (C). Range-of-motion exercises can result in paravertebral muscle spasms and increased pain (A). Bending the knees, rather than (B), reduces stress on the lower back. (D) places stress on the lower back and increases the client's pain.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A.Participating in telephone consultations with clients B.Identifying oneself by name and title to clients in telehealth communications C.Sending medical records to health care providers via the Internet D.Answering a client-initiated health question via electronic mail

C Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred (C). Client confidentiality is protected by federal wiretapping laws making telephone consultation (A) a private and protected form of communication. By stating one's name and credentials in telehealth communication (B), one is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk than sending records via the Internet.

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A.Obtain the remainder of the preoperative admission information. B.Check the vomiting client for signs of tube feeding aspiration. C.Position the client who has vomited on his side and obtain vital signs. D.Teach the preoperative client coughing and deep breathing exercises.

C The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs (C). (A and B) involve assessment, which should be performed by a nurse. (D) involves initial client teaching, which should be performed by the nurse.

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A.An adolescent who was readmitted to the hospital because of a postoperative infection B.A woman with a new colostomy who requires discharge teaching C.A woman who had a hip replacement and may be transferred to the home care unit D.A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction

C The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs (A). The client is infected and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support (D). This may require skills beyond the level of this UAP.

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A.The client is noncompliant with his medications. B.The client recently consumed large quantities of pears or nuts. C.The client's renal function has affected his potassium level. D.The client needs to be started on a potassium supplement.

C The client has a normalized potassium level despite diuretic use (C). The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment (A). Pears and nuts do not affect the serum potassium level (B). There is no need for a potassium supplement (D) because the client's potassium level is within the normal range.

The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide? A.This visual acuity result is five times worse that of a normal finding. B.This line should be seen clearly when the client wears corrective lenses. C.A client with normal vision can read at 100 feet what this client reads at 20 feet. D.This client can see at 100 feet what a client with normal vision can see at 20 feet.

C The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100 means that this client can read at 20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are inaccurate.

Which action by the nurse is consistent with culturally competent care? A.Treating each client the same regardless of race or religion B.Ensuring that all Native American clients have access to a shaman C.Understanding one's own world view in addition to the client's D.Including the family in the plan of care for older clients

C The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views (C). Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity (A, B, and D).

A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? A.Advocate for the rights of the staff to watch television once their assignments are complete. B.Confront the administrator about making a decision that will negatively affect the residents. C.Offer to develop an alternate solution so that the residents can continue to watch television. D.Remind the administrator that watching television helps the night shift staff remain awake.

C The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise (C). The staff do not have the right to watch television (A) while being paid to work. (B) challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. (D) is not a sound rationale for the use of the television.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A.As women age, they often become rounder in the middle because they do not exercise properly. B.Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C.With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D.Because there is no evidence of a diseased colon, there is no need to worry about abdominal size

C With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing.

A child has cystic fibrosis. Which statement by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions? A) "I will restrict fluids during mealtimes." B) "I will discontinue the use of salt while cooking." C) "I should provide high-calorie foods between meals." D) "I should eliminate whole milk products from the diet."

C) "I should provide high-calorie foods between meals." - Children with cystic fibrosis require 150% more calories than the average child. Fluids should not be restricted because patients with CF have thick secretions and fluids will thin them out. There is no need to eliminate salt or dairy from the diet.

A nurse is counseling a postmenopausal obese client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss. Select all that apply. A) "I must go on a strict diet." B) "I will take 400 mg of vitamin D daily." C) "I should take 1200 mg of calcium daily." D) "Swimming or bike riding 5 times a week is good for me." E) "Joining an aerobics class 3 times a week will help my bones."

C) "I should take 1200 mg of calcium daily." E) "Joining an aerobics class 3 times a week will help my bones."

While awaiting the biopsy report before removal of a tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond? A) "Worrying is not going to help the situation." B) "Let's wait until we hear what the biopsy report says." C) "It is very upsetting to have to wait for a biopsy report." D) "Operations are not performed unless there are no other options."

C) "It is very upsetting to have to wait for a biopsy report."

A client asks the nurse if glipizide (Glucotrol) is an oral insulin. Which response should the nurse provide? A) "Yes, it is an oral insulin and has the same actions and properties as intermediate insulin." B) "Yes, it is an oral insulin and is distributed, metabolized, and excreted in the same manner as insulin." C) "No, it is not an oral insulin and can be used only when some beta cell function is present." D) "No, it is not an oral insulin, but it is effective for those who are resistant to injectable insulins."

C) "No, it is not an oral insulin and can be used only when some beta cell function is present." - An effective oral form of insulin has not yet been developed (C) because when insulin is taken orally, it is destroyed by digestive enzymes. Glipizide (Glucotrol) is an oral hypoglycemic agent that enhances pancreatic production of insulin. (A, B, and D) do not provide accurate information.

A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? A) Sprinkle the powder from the capsule into a cup of water B) Insert a rectal suppository containing 100 mg of phenytoin C) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL D) Obtain a change in the administration route to allow an IM injection

C) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL

A client's dose of isosorbide dinitrate (Imdur) is increased from 40 mg to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled dose, which action should the nurse implement? A) Hold the next scheduled dose of Imdur 60 mg and administer a PRN dose of acetaminophen (Tylenol). B) Administer the 40 mg of Imdur and then contact the healthcare provider. C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). D) Do not administer the next dose of Imdur or any acetaminophen until notifying the healthcare provider.

C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). - Imdur is a nitrate which causes vasodilation. This vasodilation can result in headaches, which can generally be controlled with acetaminophen (C) until the client develops a tolerance to this adverse effect. (A and B) may result in the onset of angina if a therapeutic level of Imdur is not maintained. Lying down (D) is less likely to reduce the headache than is a mild analgesic.

A client with a third-degree uterine prolapse is scheduled for a vaginoplasty. What should the nurse anticipate the surgeon will order? A) Encourage ambulation B) Elevate the foot of the bed C) Apply moist compresses to the uterus D) Support the prolapsed uterus with a sanitary pad

C) Apply moist compresses to the uterus

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. A) Polyuria B) Jaundice C) Azotemia D) HTN E) Polycythemia

C) Azotemia E) Polycythemia

During a colostomy irrigation, a client reports feeling abdominal cramps. What should the nurse do in response to the client's statement? A) Discontinue the irrigation B) Lower the container of fluid C) Clamp the catheter for a few minutes D) Advance the catheter approximately an inch

C) Clamp the catheter for a few minutes

A client is experiencing an adverse effect of the gastrointestinal stimulant metoclopramide HCl (Reglan). Which assessment finding would require immediate intervention by the nurse? A) Complains of dizziness when first getting up B) Describes an unpleasant metallic taste in the mouth C) Demonstrates Parkinson's-like symptoms, such as cogwheel rigidity D) Refuses to drive after 6 pm because of an inability to see well at night

C) Demonstrates Parkinson's-like symptoms, such as cogwheel rigidity - Metoclopramide HCl (Reglan) blocks dopamine receptors in the brain, which can cause the extrapyramidal symptoms associated with Parkinson's disease (C). Reglan has been associated with hypertension, not (A). (B) is often associated with metronidazole (Flagyl), not metoclopramide HCl (Reglan). (D), and other vision problems, have not been associated with metoclopramide HCl (Reglan).

A nurse is teaching a client with a permanent colostomy about self-care in preparation for discharge from the hospital. Which intervention should the nurse discuss with the client? A) Limiting activity B) Wearing special clothing C) Dilating the stoma periodically D) Maintaining a low-residue diet

C) Dilating the stoma periodically

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites? A) Portal hypertension B) Kidney malfunction C) Diminished plasma protein level D) Decreased production of potassium

C) Diminished plasma protein level

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A) Review the chart for a signed consent for hospitalization. B) Get the health care provider's permission to give the medication. C) Do not give the medication and document the reason. D) Complete an incident report and notify the parents.

C) Do not give the medication and document the reason. - The nurse should not give the medication and should document the reason (C) because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent (A) or a health care provider's permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary unless the medication had previously been administered.

A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus? A) Cortical hormones stimulate rapid weight loss. B) Tissue catabolism results in a negative nitrogen balance. C) Glucocorticoids accelerate the process of gluconeogenesis. D) Excessive adrenocorticotropic hormone (ACTH) secretion damages pancreatic tissue.

C) Glucocorticoids accelerate the process of gluconeogenesis. - Excess glucocorticoids cause hyperglycemia, and signs of diabetes mellitus may develop ACTH, which causes sodium retention and subsequent weight gain. Although muscle wasting is associated with excessive corticoid production, this will not cause diabetes mellitus. ACTH affects the adrenal cortex, not the pancreas.

A client is admitted to the ED with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Which medication does the nurse expect the HCP to prescribe because it will provide passive immunity for several weeks with minimal danger of an allergic reaction? A) Tetanus toxoid B) Equine tetanus antitoxin C) Human tetanus antitoxin D) DTaP vaccine

C) Human tetanus antitoxin

Which nursing intervention is most important when caring for a client receiving the antimetabolite cytosine arabinoside (Arc-C) for chemotherapy? A) Hydrate the client with IV fluids before and after infusion. B) Assess the client for numbness and tingling of extremities. C) Inspect the client's oral mucosa for ulcerations. D) Monitor the client's urine pH for increased acidity.

C) Inspect the client's oral mucosa for ulcerations. - Cytosine arabinoside (Arc-C) affects the rapidly growing cells of the body, therefore stomatitis and mucosal ulcerations are key signs of antimetabolite toxicity (C). (A, B, and D) are not typical interventions associated with the administration of antimetabolites.

A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? A) Behind the client B) In front of the client C) On the client's left side D) On the client's right side

C) On the client's left side - When the nurse is assisting the client to ambulate, she should stand on the client's stronger, unaffected side.

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? A) Stop the flow of unoxygenated blood into systemic circulation. B) Increase the flow of unoxygenated blood to the lungs. C) Prevent the return of oxygenated blood to the lungs. D) Reduce peripheral tissue hypoxia and nailbed clubbing.

C) Prevent the return of oxygenated blood to the lungs. - Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.

A nurse is caring for a client with an undescended testicle. The nurse teaches the client that the main reason why the testicles are suspended in the scrotum is to: A) Protect the sperm from the acidity of urine B) Facilitate the passage of sperm through the urethra C) Protect the sperm from high abdominal temperatures D) Facilitate their maturation during embryonic development

C) Protect the sperm from high abdominal temperatures

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? A) Increased physical activity B) Absence of further outbursts C) Relaxation of tensed muscles D) Denial of the need for further discussion

C) Relaxation of tensed muscles - Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

Which nursing action is protected from legal action? A) Providing health teaching regarding family planning B) Offering first aid at the scene of an automobile collision C) Reporting incidence of suspected child abuse to the appropriate authorities D) Administering resuscitative measures to an unconscious child pulled out of a swimming pool

C) Reporting incidence of suspected child abuse to the appropriate authorities -

A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals? A) Metabolic acidosis. B) Metabolic alkalosis. C) Respiratory acidosis. D) Respiratory alkalosis.

C) Respiratory acidosis. - Respiratory acidosis (C) results from retention of CO2 secondary to hypoventilation due to respiratory depression, which is an adverse effect of opiates. Metabolic acidosis (A) is caused by chronic renal failure, loss of bicarbonates during diarrhea, and metabolic disorders that result in overproduction of lactic acid or ketoacids. Metabolic alkalosis (B) is caused by excessive loss of gastric acid and administration of alkalinizing salts. Respiratory alkalosis (D) is precipitated by hyperventilation.

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? A) The oxygen had not been ordered and therefore should not have been administered B) The symptoms were too vague for the nurse to determine a need for administering oxygen C) The nurse's observations were sufficient, and the oxygen should have been administered D) The HCP should have been called for an order before the nurse administered the oxygen

C) The nurse's observations were sufficient, and the oxygen should have been administered - The Nurse Practice Act states that nurses diagnose and treat human responses to actual or potential health problems. Administration of oxygen is an emergency situation and is within the scope of nursing practice.

A nurse is teaching a client how to self-administer a medicated douche. In which direction should the nurse instruct the client to direct the douche nozzle? A) To the left B) To the right C) Toward the sacrum D) Toward the umbilicus

C) Toward the sacrum

The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy? A) Dystonia. B) Akathisia. C) Weight gain. D) Photosensitivity.

C) Weight gain. - Risperidone (Risperdal, Consta) is an atypical antipsychotic agent with a lower potential for extrapyramidal effects, but cause common side effects, such as weight gain (C), insomnia, hypotension, and headache. Atypical antipsychotics are less likely to induce extrapyramidal side effects (EPS) (movement disorders), such as pseudoparkinsonism and tardive dyskinesia, where as (A, B, and D) are more likely to occur during therapy with conventional phenothiazine antipsychotics.

Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?

Case manager.

549. A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information?

Catheterize for residual urine after next voiding

The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?

Change in level of consciousness. Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function.

289. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Check for a destined bladder

38. When assessing a multigravada the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? a) Massage the uterus to decrease atony b) Review the hemoglobin to determine hemorrhage c) Increase intravenous infusion d) Check for a distended bladder

Check for a distended bladder

459. The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?

Check the TPN solution for cloudiness

20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

Cleanse the foot with soap and water and apply an antibiotic ointment

Prior to insertion of an indwelling urinary catheter, what client information is most important for the nurse to obtain?

Client allergies to antiseptic solutions

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the clients prescribes medications?

Clopidogrel (Plavix), an antiplatelet agent, given orally

460. A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications?

Clopidogrel (Plavix), an antiplatelet agent, given orally Methylprednisolone (solu-medrol), a corticosteroid, to be given IV Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous

After eye drops are instilled, which instruction should the nurse provide to the client?

Close your eyelids.

583. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?

Cloudy dialysate output and rebound abdominal pain

8. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? a) Finger stick blood glucose 120 mg/dL post exchange b) Arteriovenous (AV) graft surgical site pulsations. c) Anorexia and poor intake of adequate dietary protein d) Cloudy dialysate output and rebound abdominal pain

Cloudy dialysate output and rebound abdominal pain

134. A frail elderly woman fell at home and broke her hip. Because of her advanced age, which postoperative assessment is most important for the NURSE to include in the client's plan of care? a) Daily hemoglobin and hematocrit. b) Cognitive acuity and level of orientation c) Bowel sounds and bowel movements frequency. d) Urinary output related to total fluid intake.

Cognitive acuity and level of orientation

623. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

Collect a urine specimen for routine urinalysis

204. A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.)

Collect multiple site screening culture for MRSA Place the client on contact transmission precautions Continue to monitor for client sign of infection.

452. A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

Complete pre-infusion checklist

An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

Completely stop cigarette/ cigar smoking

221. An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

Completely stop cigarette/ cigar smoking.

412. The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber?

Compress the drip chamber

630. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Compulsion

An adult female client is admitted to the psychiatric unit because of a complex handwashing that takes two hours or longer to complete. She worries about staying clean and refuses to sit...client's handwashing is an example of which clinical behavior?

Compulsion

458. A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?

Condition of hair, nails, and skin

The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?

Confidentiality.

107. At bedtime, an unlicensed assistive personnel (UAP) is positioning a client with obstructive sleep apnea syndrome (OSAS). The UAP elevates the head of the bed and encourages the client to turn n on the side. In supervising the UAP, what action should the nurse take? a) Reposition the client in supine position with the feet elevated on pillows b) After leaving the room, discuss correct positioning with the UAP c) Remind the UAP to pad the side rails to reduce risk for injury d) Confirm that the UAP has placed the call bell within reach of the client

Confirm that the UAP has placed the call bell within reach of the client

200. A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?

Confirm the desired effect of the medication has been achieved.

106. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Confirm the necessity for continued use of the CVC.

A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement?

Confront the client about the consequences of the behavior.

105. A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Confusion and papilledema

A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Confusion and papilledema

329. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?

Confusion and tremors

149. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Contact the medical records department supervisor.

359. A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife's birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the client's blood pressure hourly

81. Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the progress of labor.

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

Continue to monitor the rate of drainage

287. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement?

Continue with the plan of care for this client

553. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases?

Contraction pattern

604. The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?

Contractions of the sternocleidomastoid muscle

175. The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Convey to the client that birth is imminent.

When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care?

Coordinating and educating about multidisciplinary services.

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care The correct answer is D: Supervise a nursing assistant for skin care.

D

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A.French toast sticks and orange juice B.Sausage egg muffin and grape juice C.Canadian bacon slices and hot chocolate D.Toasted oat cereal and low-fat milk

D A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and C) are high in fat and sodium.

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A."Let's play some dominoes for a few minutes." B."I don't think the violence means the world is ending." C."The news makes you have upsetting thoughts." D."Listening to the news seems to be frightening you."

D A client's delusional statements are best addressed by identifying the feeling associated with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system (B). The client is unlikely to understand the relationship between the news and the thoughts experienced (C).

An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? A.Turn off the client's television and speak very loudly. B.Communicate in writing whenever it is possible. C.Speak very slowly while exaggerating each word. D.Face the client and speak in a normal tone of voice.

D A hearing-impaired client frequently relies on lip reading and body language to determine what is being said, so (D) should be implemented. (A and C) may distort the sounds and facial expressions, which alters the client's ability to interpret the verbal message. Communicating in writing is another option that could be used if verbal or body language is ineffective (B).

A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol). How should the nurse respond to this client's statement? A.Bleeding precautions should be implemented. B.Tylenol is indicated for minor aches and pains. C.Acetaminophen reduces inflammation. D.The drug is hepatotoxic and contraindicated.

D Acetaminophen is hepatotoxic and can cause further complications for a client with impaired liver function, so its use is contraindicated (D). Although bleeding (A) is a risk in clients with liver disease caused by decreased production of clotting components, this drug significantly increases this risk and is contraindicated. Although (B) is an indicated use for this drug, it remains contraindicated in patients with hepatic failure. (C) is inaccurate.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A.High Fowler's position without a pillow behind the head B.Semi-Fowler's position with a single pillow behind the head C.Right side-lying position with the head of the bed elevated 45 degrees D.Sitting upright and forward with both arms supported on an over the bed table

D Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table (D) allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler's position does not allow maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the thoracic cage (B). Positioning a client on the right side with the head of the bed elevated (C) does not facilitate lung expansion.

The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? A.The pupils become equal and reactive to light. B.The right pupil constricts within 30 minutes. C.Bilateral visual accommodation is restored. D.The right pupil dilates after drop installation.

D Atropine (Isopto Atropine) is a mydriatic drug, which causes pupil dilation and paralysis in preparation for surgery or examination (D). (A, B, and C) do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A.Ask the UAP to check for the advanced directive while the nurse completes the assessment. B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C.Check the medical record for the advanced directive and then complete the client assessment. D.Call for the charge nurse to check the advanced directive while continuing to assess the client.

D Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A.Remove the client's nail polish and dentures. B.Assist the client to the restroom to void. C.Obtain the client's height and weight. D.Offer the client emotional support.

D By using therapeutic techniques to offer support (D), the nurse can determine any client concerns that need to be addressed. (A, B, and C) are all actions that can be performed by the UAP under the supervision of the nurse.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A."Is your son's short stature a social embarrassment to him or the family?" B."What types of foods do both your children eat now and what did they eat when they were infants?" C."Did any significant trauma occur with the birth of your son?" D."Did your daughter also start her menstrual period at 12 years of age?"

D Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins (D). (A) is not appropriate at this time. The mother is worried that something is wrong with her son physically. (B) has less to do with stature than growth and development. (C) is not related to growth hormone deficiencies, which are idiopathic (without known causes).

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A."Have you ever been told that you have hardening of the arteries?" B."Do you frequently experience eye pain?" C."Do you have high blood pressure or kidney problems?" D."Does anyone in your family have glaucoma?"

D Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member (D). (A and C) are not related to glaucoma. Glaucoma rarely causes pain (B), which is why screening is so important.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A."What makes you think we did anything to your baby?" B."Are you or any of your blood relatives of Asian descent?" C."Those are stork bites and will go away in about 2 years." D."Those are Mongolian spots and will gradually fade in 1 or 2 years."

D Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned babies. (A) is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African decent, (B) does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites (C), appear reddish-purple or red and are usually on the face or head and neck area.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A.Clients' names are not used while they are in a public waiting room. B.Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C.Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D.Old medical records are kept in a locked file cabinet in the department.

D Past medical records must be "secured" and "reasonably protected" from inadvertent viewing (D). A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without their diagnosis or treatment) is not considered confidential or PHI (A). Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous (B), but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions (C).

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; Pco2,50 mm Hg; Po2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results? A.Metabolic acidosis B.Respiratory alkalosis C.Metabolic alkalosis D.Respiratory acidosis

D Rationale: A pH <7.25 and Pco2 >45 mm Hg with a normal HCO3 indicates respiratory acidosis (D). The others are incorrect analyses of the ABGs (A, B, and C).

A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? A."It's normal to feel ambivalent about a pregnancy when you are not feeling well." B."I think you should discuss these feelings with your health care provider." C."How does the father of your child feel about your having this baby?" D."Tell me about these second thoughts you are having about this pregnancy."

D Rationale: Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It is reflective and keeps the lines of communication open. (A) is not the best response because it offers false reassurance. (B) dismisses the client's feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be discussed, but it is not the most important information to obtain at this time.

The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? A.Increase the rate of the heparin infusion using a nomogram. B.Decrease the heparin infusion rate and give vitamin K IM. C.Continue the heparin infusion at the current prescribed rate. D.Stop the heparin drip and prepare to administer protamine sulfate.

D Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for hemorrhage (C).

A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A."I will not take my digoxin if my heart rate is higher than 100 beats/min." B."I should weigh myself once a week and report any increases." C."It is important to increase my fluid intake whenever possible." D."I should report an increase of swelling in my feet or ankles."

D Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C).

The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care? A.Palpate for pitting edema. B.Provide meticulous skin care. C.Administer phosphate binders. D.Monitor serum potassium levels.

D Rationale: Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening (D). One sign of fluid retention is pitting edema (A), but it is an expected symptom of renal failure and is not as high a priority as (D). (B and C) are common nursing interventions for CRF but not as high a priority as (D).

Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? A.Accelerations in response to fetal movement B.Early decelerations in the second stage of labor C.Fetal heart rate of 130 beats/min between contractions D.Late decelerations with absent variability and tachycardia

D Rationale: Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous (D). 130 beats/min is an expected heart rate (C). The others are not as critical (A and B).

The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first? A.Restrain the client to protect from injury. B.Flex the neck to ensure stabilization. C.Use a tongue blade to open the airway. D.Turn client on the side to aid ventilation.

D Rationale: Maintaining airway during a seizure is priority for safety (D). (A, B, and C) are contraindicated during a seizure and may cause further injury to the client.

A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A.Increased hemoglobin and hematocrit levels B.Increased serum calcium level C.Decreased white blood cell (WBC) count D.Decreased triiodothyronine (T3) and thyroxine (T4) levels

D Rationale: Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones (D). It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It is does not affect (A). (B) must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and (C) monitored.

When assessing safety for the older adult, which of the following is of highest priority to the nurse? A.The client has a cataract in the right eye. B.The client is not married and lives alone. C.The client lives in a two-story building. D.The client reports a history of repeated falls.

D Rationale: Risk assessment for falls is a critical element in caring for the older adult. (A, B, and C) are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again (D).

An older client calls the clinic and complains of feeling very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because of constipation. What is the most likely cause of the client's symptoms? A.Mucosal bleeding B.Sodium retention C.Fluid volume depletion D.Water intoxication

D Rationale: Tap water is a hypotonic fluid that can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication (D). This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause mucosal irritation, which might result in some bleeding (A), but the client would not experience weakness and dizziness unless she was hemorrhaging. (B and C) can occur with the use of a hypertonic rather than hypotonic solution.

An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A.Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B.Explain that treatment is based on information obtained in the assessment. C.Encourage the client to relax so that she can provide the information requested. D.Empower the client to share her story of why she is here at the mental health clinic.

D Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety.

Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)?A.Reorient the client to surroundings. B.Assess blood pressure every 15 minutes. C.Determine if muscle soreness is present. D.Maintain a patent airway.

D Rationale: The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway (D). Patients may be confused after ECT (A), but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority (B). Muscle soreness is an expected finding after ECT (C).

The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A."I know many women who have survived ovarian cancer." B."Let's talk about the treatments of ovarian cancer." C."In my opinion I would suggest getting a second opinion." D."Tell me about what you are feeling right now."

D Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings (D). Giving false reassurance or personal suggestions are not therapeutic communication for the client (A, B, and C).

The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A.An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents B.A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose C.A women at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency D.A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn

D Rationale: The women with epigastric pain should be called first (D). One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. (A, B, and C) are less serious and should be called after (D).

The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? A.0.5 B.1.8 C.5 D.9

D Rationale:15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 ml = 9 mL

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A.Reduced peripheral edema B.Urinary output of at least 70 mL/hr C.Decrease in urine osmolarity D.Serum sodium level of 137 mEq/L

D Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema (A), but the higher priority outcome is the effect on serum electrolyte levels. Although (B and C) are findings associated with resolving SIADH, they do not have the priority of (D).

A nurse is planning patient care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A.Review the plan and the steps in performing the procedure with another nurse. B.Look up the specific procedure in a medical surgical nursing text on the unit. C.Discuss the client's prescribed procedure with an available health care provider. D.Consult the agency's policies and procedures manual and follow the guidelines.

D The agency's policies and procedures manual (D) should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. (A and B) may be resources, but client care should be implemented according to the agency's published policies and procedures. (C) is not practical.

A male client with Parkinson's disease has been taking the antiparkinsonian agent amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The medicine doesn't seem to be working anymore." Which information should the nurse provide to this client? A.The dosage probably needs to be increased. B.The medication needs to be changed immediately. C.The medication needs to be taken more frequently. D.The effects of this drug tend to decrease after 3 months.

D The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be discontinued gradually if necessary (B). Sometimes it is discontinued for a period of time and then resumed at a higher dosage, and although (A) is partially correct, (D) is more correct. Sometimes Symmetrel is given with other antiparkinsonian medications as an adjunct, but (C) would have little effect.

Which client is best to assign to a graduate PN who is being oriented to a renal unit? A.A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B.A client who is receiving continuous ambulatory peritoneal dialysis C.A client with continuous bladder irrigation for hematuria D.A client with renal calculi whose urine needs to be strained

D The client with renal calculi (kidney stones) (D) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. (A, B, and C) require careful assessment from an experienced nurse because of the potential for significant complications.

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take? A.Open the airway with a chin lift-head tilt maneuver. B.Obtain a fingerstick glucose reading. C.Administer flumazenil (Romazicon). D.Continue to monitor the client.

D The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked diplopia. Because this is the desired outcome of the medication regimen, no action is needed but continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.

D The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP.

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A.A primigravida who is 8 cm dilated after 14 hours of labor B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation C.A client being induced for fetal demise at 20 weeks' gestation D.A multiparous client who is dilated 5 cm and 50% effaced

D The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, (D) is progressing well and is the least complicated. (A, B and C) have actual or potential complications and should be assigned to a more experienced nurse.

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A.The respiratory settings on the ventilator B.Only the client's spontaneous respirations C.The ventilator-assisted respirations minus the client's independent breaths D.The ventilator setting for respiratory rate and the client-initiated respirations

D The nurse should count the client's respirations, and document both the respiratory rate set by the ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client (B and C).

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? A.A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B.A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C.An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D.A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

D The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults.

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement? A.Request a prescription for a bed board to provide increased back support. B.Reposition the client so that both feet are supported by the bed board. C.Move the trapeze bar to allow the client to pull with the upper extremities. D.Place trochanter rolls on the lateral aspects of the client's thighs.

D Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although (A, B, and C) are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board (A) provides increased back support, especially with a soft mattress. The footboard (B) maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar (C) allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.

The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A.Prepare to evacuate the unit, starting with the bedridden clients. B.UAPs should report to the emergency center to handle transports. C.The licensed staff should begin counting wheelchairs and IV poles on the unit. D.Continue with current assignments until more instructions are received.

D When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A) "Is your son's short stature a social embarrassment to him or the family?" B) "What types of foods do both your children eat now and what did they eat when they were infants?" C) "Did any significant trauma occur with the birth of your son?" D) "Did your daughter also start her menstrual period at 12 years of age?"

D) "Did your daughter also start her menstrual period at 12 years of age?" - Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins (D). (A) is not appropriate at this time. The mother is worried that something is wrong with her son physically. (B) has less to do with stature than growth and development. (C) is not related to growth hormone deficiencies, which are idiopathic (without known causes).

After a hysterosalpingo-oophorectomy, a client wants to know whether it would be wise for her to take hormones right away to prevent symptoms of menopause. WHat is the nurse's most appropriate response? A) "It is best to wait because you may not have any symptoms." B) "It is comforting to know that hormones are available if you should ever need them." C) "You have to wait until symptoms are severe; otherwise, hormones will have no effect." D) "Discuss this with your HCP, because it is important to know your concerns."

D) "Discuss this with your HCP, because it is important to know your concerns."

A parent whose newborn infant son has a cleft lip and palate asks the nurse, "How should I feed my baby because he has difficulty sucking?" What information should the nurse provide concerning a safe feeding technique for the infant? A) "Since he tires easily, it is best to have him lying in bed while he is being fed." B) "He should be held in a horizontal position and fed slowly to avoid aspiration." C) "Try using a soft nipple with an enlarged opening so he can get milk through a chewing motion." D) "Give him brief rest periods and frequent burpings during feedings so that he can get rid of swallowed air."

D) "Give him brief rest periods and frequent burpings during feedings so that he can get rid of swallowed air." - Infants with cleft lips and palates tend to swallow a lot of air, so frequent rest periods and burping are the best teaching for this client.

A nurse is teaching a client about a restricted diet. What is the nurse's best initial comment? A) "What type of foods do you usually eat?" B) "You should follow this diet exactly as written." C) "You must limit the intake of foods on this special list." D) "What do you know about this diet that was ordered for you?"

D) "What do you know about this diet that was ordered for you?"

The nurse has completed diabetic teaching for a client who has been newly diagnosed with diabetes mellitus. Which statement by this client would indicate to the nurse that further teaching is needed? A) "Regular insulin can be stored at room temperature for 30 days." B) "My legs, arms, and abdomen are all good sites to inject my insulin." C) "I will always carry hard candies to treat hypoglycemic reactions." D) "When I exercise, I should plan to increase my insulin dosage."

D) "When I exercise, I should plan to increase my insulin dosage." - Exercise helps facilitate the entry of glucose into the cell, so increasing insulin doses with exercise would place the client at high risk for a hypoglycemic reaction (D). (A, B, and C) reflect accurate statements about the use of insulin and management of hypoglycemic reactions.

A nurse is monitoring a client's fasting plasma glucose. At which FPG level should the nurse identify that the client has prediabetes? A) 70 mg/dL B) 100 mg/dL C) 130 mg/dL D) 160 mg/dL

D) 160 mg/dL

What should the nurse do when caring for a client with an ileostomy? A) Teach the client to eat foods high in residue B) Explain that drainage can be controlled with daily irrigations C) Expect the stoma to start draining on the third postoperative day D) Anticipate that any emotional stress can increase intestinal peristalsis

D) Anticipate that any emotional stress can increase intestinal peristalsis

A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide? A) Peanuts B) Pretzels C) Bananas D) Applesauce

D) Applesauce - Applesauce is the most nutritious selection. Bananas are high in potassium and are contraindicated in patients with glomerulonephritis.

A client undergoes cardiac catheterization via femoral artery because of a history of bilateral mastectomies. What is the most important nursing action after the procedure? A) Provide a bed cradle B) Check for a pulse deficit C) Elevate the head of the bed D) Assess the groin for bleeding

D) Assess the groin for bleeding - Hematoma and hemorrhage are common complications after cardiac catheterization.

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child? A) Age. B) Height. C) Weight. D) Body surface area.

D) Body surface area. - The most accurate method of calculating pediatric doses is based on a child's body surface area (BSA) (D). Drug calculations are not consistently precise when made on the basis of a child s age (A) since children vary widely in size and maturity for chronologic age. Although the calculation of a child's BSA utilizes a child's height and weight, (B and C) alone do not correlate with the distribution or metabolism of a drug due to the variance in each child's growth and development

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take? A) Open the airway with a chin lift-head tilt maneuver. B) Obtain a fingerstick glucose reading. C) Administer flumazenil (Romazicon). D) Continue to monitor the client

D) Continue to monitor the client - The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked diplopia. Because this is the desired outcome of the medication regimen, no action is needed but continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A) Only refer to the client by gender. B) Identify the client only by age. C) Avoid using the client's name. D) Discuss the client another time.

D) Discuss the client another time. - The best nursing action is to discuss the client another time (D). Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender (A) or age (B), and even when not using the client's name (C).

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? A) Summon assistance of several other staff. B) Send the other clients out of the group setting. C) Tell the client to leave the group to gain control of the behavior. D) Firmly inform the client that acting out anger is not acceptable.

D) Firmly inform the client that acting out anger is not acceptable. - A client with hypomania may demonstrate a varying degree of feelings, rapid thoughts, speech patterns, and impulsive acts. The client should be informed firmly that threats or behavior to act out feelings of anger is not acceptable (D). Staff assistance should be summoned (A) only if the client becomes aggressive and out of control. If a client persists with threats or aggressive behavior, changing the client's environment should be implemented before (B). Although personal time away from the group (C) may allow the client time out, the client should be confronted to recognize that the behavior is unacceptable.

A nurse at the fertility clinic is counseling a couple about the tests that will be needed to determine the cause of their infertility. Which test should the nurse describe that will evaluate the woman's organs of reproduction? A) Biopsy B) Cystogram C) Culdoscopy D) Hysterosalpingogram

D) Hysterosalpingogram

A nurse is assessing two clients. One client has UC and the other client has Crohn disease. Which is more likely to be identified in the client with UC? A) Inclusion of transmural involvement of the small bowel wall B) Correlation with increased malignancy because of malabsorption syndrome C) Pathology beginning proximally with intermittent plaques found along the colon D) Involvement starting distally with rectal bleeding that spreads continually up the colon

D) Involvement starting distally with rectal bleeding that spreads continually up the colon

What does the nurse expect to be the priority concern of a 28-year-old woman who has to undergo a laparoscopic bilateral salpingo-oophrectomy? A) Acute pain B) Risk for hemorrhage C) Fear of chronic illness D) Loss of childbearing potential

D) Loss of childbearing potential

A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect to be ordered in preparation for this surgery? A) Bland B) Clear liquid C) High-protein D) Low-residue

D) Low-residue

A pregnant adolescent at 10 weeks' gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate? A) Caloric content will result in too great a weight gain B) Ingredients in soft drinks and candy can be teratogenic during pregnancy C) Salt in this diet will contribute to the development of gestational hypertension D) Nutritional composition of the diet places her at risk for a low-birth weight infant

D) Nutritional composition of the diet places her at risk for a low-birth weight infant

Which action should the nurse implement to assess for jugular vein distention (JVD) in a client with heart failure (HF)? A) Ask the client to perform the Valsalva maneuver while lying in a supine position. B) Palpate the jugular veins, comparing the volume and pressure of one with those of the other. C) Measure in centimeters the distance that the jugular veins are distended outward from the neck. D) Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

D) Observe the vertical distention of the veins as the client is gradually elevated to an upright position. - An indicator of elevated right atrial pressure in HF is jugular distention of greater than 3 cm vertical distance between the intersection of the angle of Louis and the level of the jugular distention, which occurs when the client is gradually elevated to an upright position (D). (A, B, and C) do not provide the best evaluation of JVD in a client with HF.

A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain will most likely remain contaminated with hepatitis A virus after being cooked? A) Canned tuna B) Broiled shrimp C) Baked haddock D) Steamed lobster

D) Steamed lobster

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge? A) The nurse counseling a client at the time of grief B) The nurse administering an intravenous infusion to a client C) The nurse teaching the client about an appropriate nutrition plan D) The management of the client's environment to prevent infections

D) The management of the client's environment to prevent infections - Nursing interventions are based on clinical judgment and knowledge and performed by the nurse for enhancing the client's outcomes. Indirect care interventions are treatments which are performed away from the client but will benefit the client. Managing the client's environment to prevent infection control is an indirect care intervention. Direct care interventions are performed through interactions with the clients. Direct care interventions may include counselling the client at the time of grief, administering an intravenous infusion to the client, and teaching the client about an appropriate nutrition plan.

An older adult is hospitalized for weight loss and dehydration because of nutritional deficits. What should the nurse consider when caring for this client? A) Financial resources usually are unrelated to nutritional status B) An older adult's daily fluid intake must be markedly increase C) The client's diet should be high in carbohydrates and low in proteins D) The nutritional needs of an older adult are unchanged except for a decreased need for calories

D) The nutritional needs of an older adult are unchanged except for a decreased need for calories

What potential complication does the nurse anticipate when admitting a client with the diagnosis of severe prolapse of the uterus? A) Edema B) Fistulas C) Exudate D) Ulcerations

D) Ulcerations

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? A) Length of time the client has been wearing prescription lenses. B) Recent experience of seeing light flashes or floaters. C) Complaints of any blind spots in the client's field of vision. D) Use of prescribed eye drops since last exam by ophthalmologist.

D) Use of prescribed eye drops since last exam by ophthalmologist. - Normal intraocular pressures range between 10 and 21 mmHg, so the client's use of any prescribed eye drops should be determined to evaluate the client's intraocular pressure (D). Although (A, B, and C) should be determined to screen for other ophthalmic disorders, the use of an ophthalmic prescription for glaucoma focuses the evaluation of the client's IOP status.

112. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet? a) Frequently eats fruits and vegetables at meals and between meals b) Demonstrates a willingness to adhere to the diet consistently c) Has someone available who can prepare and oversee the diet d) Knows that insulin must be given 30 minutes before eating

Demonstrates a willingness to adhere to the diet consistently

A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?

Denial related to the loss of a loved one.

135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

Describes life without purpose

Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids?

Describes working hard to develop muscles.

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms

Destruction of joint cartilage

136. After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Determine client's pulse, blood pressure, and respirations

431. A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?

Determine current sexual practice

108. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

Determine if she can ask for support from family, friend, or the baby's father.

375. The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first?

Determine if the clamp on the IV tubing is released

187. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Determine the client's vital sign.

370. A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Determine type of chemical exposure.

66. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

Determine which side of the body is weak.

487. The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents?

Development progress from head to rump

581. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse?

Diabetic ketoacidosis and titrated IV insulin infusion

Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple?

Diagnostic testing may indicate a fetal problem that could be treated prior to delivery.

137. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a. Fruity breath odor b. Polyphagia c. Diaphoresis d. Polydipsia

Diaphoresis

470. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?

Diaphoresis

527. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Digitally check the client for a fecal impaction

61. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Digitally check the client for a fecal impaction

126. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Digoxin.

97. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?

Diminished left lower lobe sounds

17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Direct the nurse to continue the surgical hand scrub for a 5 minute duration

520. The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP?

Disconnect the NG suction so the client can ambulate in the hallway

328. During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first?

Discuss the concerns expressed by the client about the vaccination.

461. A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit?

Discuss the importance of continuing the usual at-home activities

189. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

During acute illness

77. A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?

Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.

622. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the...what findings is most often manifest this condition?

Ecchymosis and hematemesis

113. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Elevate the presenting part off the cord.

11. The nurse assesses a male client following surgery for a gunshot wound to the abdomen and determines that his dressing is saturated with blood and petechiae are on his extremities. His current blood pressure is 80/40, and his heart rate is 130 beats/minute. Which laboratory finding confirms the presence of disseminated intravascular coagulopathy (DIC)? a) Low prothrombin time b) Elevated fibrinogen c) Positive d-Dimer d) Normal hemoglobin

Elevated fibrinogen

43. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a. Hypernatremia b. Excessive thirst c. Elevated heart rate d. Poor skin turgor

Elevated heart rate

20. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? a) Decreased white blood cell count b) Pruritus and muscle aches c) Elevated liver function tests d) Vomiting and diarrhea

Elevated liver function tests

432. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?

Elevated liver function tests

33. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? a) Adhere to a bland diet whenever planning to eat out b) Decrease fluid intake at meal times c) Avoid foods that caused gas before the colostomy d) Eliminate foods high in cellulose

Eliminate foods high in cellulose

63. The nurse instructs a client in use of an incentive spirometer. The client performs a return demonstration as seen in the video. What action should the nurse take in response to the return demonstration? http://youtu.be/LNWGOBybQ4Q a) Auscultated the client's lungs for adventitious sounds b) Encourage the client to practice until successful c) Emphasize the need to inhale slowly into the spirometer d) Remind the client to cough after using the spirometer

Emphasize the need to inhale slowly into the spirometer

52. After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Encourage a low-carbohydrate and high-protein diet

386. A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take?

Encourage the client to continue expressing her fears and concerns.

517. An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take?

Encourage the client to describe the pain.

147. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Encourage the client to eat finger foods.

54. The parents of a 6 year old recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? a. Provide a list of alternative activities that are less likely to cause the child to experience fatigue b. Suggest that the child be encouraged to participate in a team sport to encourage socialization c. Encourage the parents to allow the child to continue attending swimming lessons with supervision d. Explain that their child is too young to understand the risks associated with swimming

Encourage the parents to allow the child to continue attending swimming lessons with supervision

Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?

Encourage the use of an incentive spirometer.

471. One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?

Encourage use of analgesics before position change

The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is appropriate to prevent these disorders from developing?

Encouraging active range-of-motion exercises

134. After administering an antipyretic medication. Which intervention should the nurse implement?

Encouraging liberal fluid intake

110. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care?

Ensure proper alignment of the leg in traction.

181. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Ensure that no dependent loops are present in the tubing.

355. A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Ensure that the infant's crib mattress is firm

281. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Ensure that the knot can be quickly released.

531. The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client's weight is accurate?

Ensure that the scale is calibrated before a weight is obtained

205. A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?

Ensure the transparent dressing has no tears that might create vacuum leaks

108. A newly hired male unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? a) Review the UAP's skills checklist and experience with the person who hired him b) Ask the nurse experienced UAP on the team to partner with the newly hired UAP c) Assign the newly hired UAP to clients who require the least complex level of care d) Evaluate the newly hired UAP's level of competency by observing him deliver care.

Evaluate the newly hired UAP's level of competency by observing him deliver care.

512. A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

Evaluate the urine osmolality and the serum osmolality values.

The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse's new role? Select all that apply.

Evaluating and updating the plan of care as needed Assessing the client's needs for home supplies and equipmentCoordinating consultations and referrals to facilitate discharge Establishing a safe and cost-effective plan of care with the client (ALL OF THESE)

411. The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?

Examine the genitalia as the last part of the total exam.

171. An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics.

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics.

278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care?

Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management

530. The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?

Flex the client's head with chin to the chest and insert.

In which order should the nurse implement these actions when withdrawing a solution from an ampule?

Flick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle. - Flicking the stem ensures all medication is in the bottom of the ampule. Wrapping the neck with a protective device (such as a small gauze pad or alcohol prep pad) protects fingers from trauma as the glass tip is broken off. Snapping the neck of the ampule quickly and outwards minimizes the nurse's risk of injury from shattering glass. Stabilizing the ampule assists in maintaining sterility as the needle is placed to withdraw the solution. Withdrawing the solution with a filter needle protects against aspirating microscopic glass into the syringe.

25. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention

The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care?

Fluid volume imbalance.

16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Foods sweetened with aspartame

344. When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply)

Fortified whole wheat cereals, whole-grain pasta, brown rice Spinach, kale, dried raisins and apricots

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation

The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?

Frequent blood pressure checks, including readings taken by automated machines, are recommended.

380. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger?

Full bladder

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly?

Help the client dangle his legs

439. During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media?

Hemophilic Influenza Type B (HiB) vaccine

170. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?

High pitched or fine crackles.

503. An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply

History of hypertension. Family heath history.

The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?

History of inflammatory bowel disorders.

155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Hold oral intake until swallow evaluation is done.

330. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings?

Hold the newborn in an upright position

591. The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take?

Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.

377. The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome?

Hot Spot

449. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).

Hot Spot

518. A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion?

Hot Spot

117. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)

Hot spot

504. A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

Human source grafts require monitoring for signs of graft rejection

A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

Human source grafts require monitoring for signs of graft rejection

Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?

Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability (C).

492. A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?

Hyperextended with neck supported by a rolled towel.

613. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

Hypernatremia

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? Hypernatremia

Hypernatremia

The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?

Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).

490. A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings?

Hypocapnea reduces ICP

60. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Hypokalemia

A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?

Hypotension, rapid weak pulse, and rapid respiratory rate.

572. A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse?

Hypotension.

19. The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? a) Early treatment is very effective b) I will clean my hot tub better c) These warts are caused by a fungus d) I need to have regular pap smears

I need to have regular pap smears

453. The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?

I need to have regular pap smears

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?

I need to have regular pap smears

The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? "

I should look at the condition of my feet every day.

164. When implementing a disaster intervention plan, which intervention should the nurse implement first?

Identify a command center where activities are coordinated

179. An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Identify pills in the bag.

121. A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first? a) Anxiety as evidenced by abdominal complaints secondary to depression b) Risk for self-directed violence as evidenced by feelings of hopelessness. c) Imbalanced nutrition as evidences by 25 pounds weight loss in four months d) Chronic low self-esteem as evidenced by feelings of worthlessness.

Imbalanced nutrition as evidences by 25 pounds weight loss in four months

86. A young woman with multiple sclerosis just received several immunizations in preparation for moving in to a dormitory. Two days later, she reports to the nurse that she is experiencing fatigue and visual problems. What teaching should the nurse provide? a) These are common side effects of the vaccines and will resolve in a few days b) Immunizations can trigger a relapse of the disease, so get plenty of extra rest c) Plans to move into the dormitory need to be postponed for at least a semester d) These early signs of an infection may require medical treatment with antibiotics

Immunizations can trigger a relapse of the disease, so get plenty of extra rest

A young woman with MS just receives several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?

Immunizations can trigger a relapse of the disease, so get plenty of extra rest.

The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement?

Immunizations that decrease occurrences of many contagious diseases Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life, such as immunization (A).

318. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply)

Include oatmeal with stewed pruned for breakfast as often as possible. Increase fluid intake by keeping water glass next to recliner. Recommend seeking help with regular shopping and meal preparation.

206. The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily

23. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? a) Increase the oxygen flow via nasal cannula if dyspnea is present. b) Place in a Trendelenburg position to increase cerebral blood flow c) Monitor capillary glucose measurements hourly during transfusion. d) Encourage increased intake of oral fluid to improve skin turgor.

Increase the oxygen flow via nasal cannula if dyspnea is present.

472. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion?

Increase the oxygen flow via nasal cannula if dyspnea is present.

145. After experiencing several transient ischemic attacks (TIA), a client is transported to the emergency room by a family member. The client has slurred speech and is becoming combative. After providing oxygen and establishing IV access. Which interventions should the nurse implement? a. Notify the stroke team b. Apply soft limb restraints c. Initiate seizure precautions d. Obtain an electroencephalography (EEG)

Initiate seizure precautions

30. When implementing a disaster intervention plan, which intervention should the nurse implement first? a) Initiate the discharge of stable clients from hospital units b) Identify a command center where activities are coordinated c) Assess community safety needs impacted by the disaster d) Instruct all essential off-duty personnel to report to the facility

Initiate the discharge of stable clients from hospital units

301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding?

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes

349. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

Inspect skin for redness Use a residual limb shrinker Wash the stump with soap and water

142. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-sided weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? a. Ask a family member to sit with the client b. Apply bilateral soft wrist restraints c. Assign staff to check client q15 minutes d. Install a bed exit safety monitoring device

Install a bed exit safety monitoring device

577. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement?

Install a bed exit safety monitoring device

548. A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?

Instill beractant 100 mg/kg in endotracheal tube.

3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

80. The legs of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personnel (UAP) place a heating pad on the mottled areas, what action should the nurse take? a) Elevate the client's feet on a pillow and monitor the client's pedal pulses frequently b) Remove the heating pad and place a soft blanket over the client's legs and feet c) Instruct the UAP to reposition the heating pads to the side of the legs and feet d) Advise the UAP to observe the client's skin while heating pads are in place.

Instruct the UAP to reposition the heating pads to the side of the legs and feet

10. A client with chronic obstructive lung disease, who is receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take? a) Ask the client to take short, rapid breaths b) Instruct the client in pursed lip breathing c) Increase oxygen to three liters/minute d) Have the client breathe into a paper bag

Instruct the client in pursed lip breathing

468. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

542. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

146. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change the child's diaper more often.

576. During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement?

Instruct the scrub nurse to re-drape the client

337. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

Instructions about how much fluid the child should drink daily

156. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)

Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply)

Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance.

A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take?

Keep the client in bed in the supine position.

88. An Unna boot is applied to the foot and lower leg of a client with a venous stasis ulcer. What instruction should the nurse provide the client? a) Wear boot whenever you are out of bed b) Keep the foot elevated as much as possible c) Loosen the bandage wrap slightly each day d) Remove the boot to wash the site once a day

Keep the foot elevated as much as possible

550. During a 26-week gestation prenatal exam, a client reports occasional dizziness...What intervention is best for the nurse to recommend to this client?

Lie on the left or right side when sleeping or resting

73. While admitting a female client with uncontrolled atrial fibrillation, the nurse teaches the client about the benefits and risks of taking the prescribed anticoagulant, warfarin sodium (Coumadin).What information should the nurse ensure that the client understands? (Select all that apply). a) Limit intake of foods that interact with medication b) INR levels are required after antibiotic therapy is completed c) Take an extra dose whenever palpitations are felt d) Herbal and over-the-counter medications can effect bleeding e) Report bleeding gums and increased bruising immediately

Limit intake of foods that interact with medication INR levels are required after antibiotic therapy is completed Herbal and over-the-counter medications can effect bleeding Report bleeding gums and increased bruising immediately

11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

Listen with the bell at the same location

76. The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?

Literacy level

610. A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

Maintain strict aseptic technique.

339. While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?

Measure the client's oral temperature

46. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement?

Measure vital signs

564. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Moderate amount of foul-smelling lochia.

161. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema.

58. A male client, newly diagnose with type 2 diabetes mellitus (DM2), awakens in the morning with a temperature of 101.6 F. He calls the clinic and reports he took his morning dose of metformin (Glucophage) after obtaining a morning fasting blood glucose of 325 mg. Which action instruction should the nurse provide to the client? a. Increase the daily dose of metformin (Glucophage). b. Watch closely for clinical manifestations of hypoglycemia c. Begin a routine sliding scale for lispro (Humalog) insulin d. Monitor blood glucose levels more frequently

Monitor blood glucose levels more frequently

37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Monitor blood pressure frequently

429. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

Monitor for an elevated temperature

85. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a) Monitor for an elevated temperature b) Measure the abdominal girth daily c) Report the onset of sclera jaundice d) Keep a record of daily urinary output

Monitor for an elevated temperature

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

Monitor for an elevated temperature

A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?

Monitor for increased blood pressure and pulse.

612. A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

Monitor heart, lung, and kidney function. Notify healthcare provider of serum amylase and lipase levels. Review client's abdominal ultrasound findings.

605. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Monitor mental status.

479. Which intervention should the nurse include in the plan of care for a client with leukocytosis?

Monitor temperature regularly

13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a) Evaluate the client's ability to use an incentive spirometer b) Monitor the amount of drainage from the client's incision c) Observe both lower extremities for redness and swelling d) Palpate all peripheral pulse points for volume and strength

Monitor the amount of drainage from the client's incision

379. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care?

Monitor the client's cardiac activity via telemetry.

133. Lactulose is prescribed for a client with hepatic encephalopathy. Which medication should the NURSE implement to evaluate the effectiveness? a) Observe the color of the client's bowel movements. b) Monitor the client's serum ammonia level. c) Assess the changes in abdominal ascites. d) Assess the client's BP frequently.

Monitor the client's serum ammonia level.

562. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care?

Monitor urine output hourly.

104. An older female client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. She has a history of smoking 2 packs of cigarettes/daily for 50 years and is currently restless and confused. Vital signs are: Temperature 96 F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure (MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dL, platelets 60,000, and white blood cell count (WBC) 3,000/mm3. Based on these findings, this client is at greatest risk for which pathophysiological condition? a) Acquired immunodeficiency syndrome (AIDS) b) Multiple organ dysfunction syndrome (MODS) c) Chronic obstructive pulmonary disease (COPD) d) Disseminated intravascular coagulation (DIC)

Multiple organ dysfunction syndrome (MODS)

196. An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?

Multiple organ dysfunction syndrome (MODS)

191. The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)

Murmur

592. A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider?

Muscle cramping

279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?

Muscle pain

425. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Muscle spasms of the back and neck

598. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?

Narrow therapeutic index.

188. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

No wheezing upon auscultation of the chest.

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high-pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

No wheezing upon auscultation of the chest.

451. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating

Normal sinus rhythm and complaining of chest pain

82. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.)

Note date and time of the behavior. Discuss the issue privately with the UAP. Plan for scheduled break times. Evaluate the UAP for signs of improvement.

294. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Notify healthcare provider to prepare for pericardiocentesis

522. The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents... holding the child as death approaches. Which intervention is most important for the nurse?

Notify nursing supervisor and hospital chaplain of the child's impending death.

9. A male client with renal cell carcinoma is returned to the unit following a radical nephrectomy. The nurse notes that his vital signs and urine output are within normal range, his bandage is dry, and the drain from the incision site is producing a small amount of serasanguinous drainage. Which intervention should the nurse implement? a) Place a pressure bandage at the drainage site b) Document assessment findings in the electronic medical record c) Monitor urinary catheter output for a decrease below 30 ml/hr d) Notify surgeon of color and amount of wound drainage.

Notify surgeon of color and amount of wound drainage

537. While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

Notify the employee health nurse.

118. An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Notify the healthcare provider of the client's change in mental status. Include q2 hour's reorientation in the client's plan of care.

320. After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take?

Notify the healthcare provider of the client's lack of understanding.

A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond?

November 21. Using Nägele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period.

A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD)... which breakfast selection by the client indicates effective learning.

Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

142. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Observe aspiration site.

436. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Observe both lower extremities for redness and swelling

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Observe both lower extremities for redness and swelling

274. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care?

Observe for changes in level of consciousness.

368. The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching?

Observe him as he demonstrates self-injection technique in another diabetic adolescent

400. A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

Observe rhythm on telemetry monitor

131. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? a) Note the appearance and patency of the client's peripheral IV site. b) Palpate the volume of the client's right radial pulse c) Auscultate the client's breath sounds bilaterally. d) Observe the amount and dose of morphine in the PCA pump syringe.

Observe the amount and dose of morphine in the PCA pump syringe.

441. The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Observe the amount of urine in the client's urinary drainage bag

53. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Observe the antecubital fossa for inflammation.

A client taking clopidogrel (Plavix) reports the onset of diarrhea. Which action should the nurse implement first?

Observe the appearance of the stool.

456. The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?

Observe the wound for dehiscence

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?

Observe the wound for dehiscence

509. The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Obtain a detailed report from the nurse transferring the client.

23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history

466. An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?

Obtain a prescription for DNR

395. An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?

Obtain a prescription for an anticholinergic medication

463. A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important?

Obtain a prescription to increase the IV rate

555. A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive...rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?

Obtain a pulse oximeter reading

353. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

Obtain vital signs and breath sounds.

348. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

Offer the client oral fluids

52. The nurse caring for a client with dysphagia is attempting to insert a nasogastric tube but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus? a. Flex the client's head with chin to the chest and insert b. Offer the client sips of water or ice and coax to swallow c. Elevate the bed 90 degrees and hyperextend the head d. Push the NGT beyond the oropharynx gently yet swiftly

Offer the client sips of water or ice and coax to swallow

563. The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond?

Offer to go with the family members to view the body.

332. A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond?

Offer to provide the influenza vaccination to the student while she is at the clinic

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel AP requires the nurse to intervene?

Offers oral fluids to the client

Which patients are most at risk for developing infective endocarditis (select all that apply.)?Select all that apply.-

Older woman with disseminated coccidioidomycosis- Homeless man with history of intravenous drug abuse- Patient with end-stage renal disease on peritoneal dialysis

99. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider?

Oliguria signals tubular necrosis related to hypoperfusion

A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?

One chronic and one acute illness.

26. It is most important for the nurse to assess which client first? a) Six hours after a pelvic fracture a client reports severe pain in the pelvic region. b) A client with deep vein thrombosis who is receiving a continuous heparin infusion. c) One day following a hip fracture, a client exhibits signs of fat embolism syndrome. d) A postoperative client scheduled to receive an IV antibiotic that has an inflamed IV site.

One day following a hip fracture, a client exhibits signs of fat embolism syndrome.

494. The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. Which nurse takes next

Open the roller clamp on the tubing.

64. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? http://youtu.be/g-h0ht4Y0uo http://youtu.be/idHRbgcHTfk a) Opening the package b) Picking up the second glove c) Picking up the first glove d) Positioning of the table

Opening the package

403. The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?

Oral temperature of 100.6 F

593. In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

Orthopnea

407. A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?

Overlook the client's behavior.

Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?

Palpate above the symphysis for the bladder. Two hours after giving birth, the uterus should be firm, in the midline, and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder, so palpating for a full bladder above the symphysis (B) should be implemented first.

117. An older woman who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about her pets. Which interventions should the nurse implement? (Select all that apply.) a) Evaluate pain using a standard pain scale b) Assess ability to bear weight when standing c) Alert social worker of client's concerns d) Support left leg with two pillows e) Palpate and mark pedal pulses

Palpate and mark pedal pulses Alert social worker of client's concerns Evaluate pain using a standard pain scale

152. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?

Palpate at the radial pulse site with the pads of two or three fingers.

557. To obtain an estimate of a client's systolic B/P. What action should the nurse take first?

Palpate the client's brachial pulse

291. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement?

Palpate the client's suprapubic area for distention

22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences

Palpitations and shortness of breath

The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?

Participants can identify at least three coping strategies to use during labor.

398. A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?

Participated actively in all treatments regimens

423. The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Participation of community leaders in planning the program

315. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply)

Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk.

541. The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-year-ol client with... Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?

Peak and through levels has not been drawn since the tobramycin was started

45. The nurse observes that a client receiving haloperidol (Haldol) is demonstrating uncontrollable facial movements. Which action is most important for the nurse to implement? a. Obtain a consult for speech therapy to assess for dysphagia b. Hold the next dose of Haldol until the health care provider is notified c. Perform a comprehensive neurologic assessment d. Provide a quiet calm environment with minimal distractions during mealtimes.

Perform a comprehensive neurologic assessment

133. The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Perform bilateral chest auscultation.

311. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?

Place a wedge under the client's right hip.

539. The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?

Place client in Trendelenburg position on the left side.

535. After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?

Place one hand on top of the other and interlace the fingers

158. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body.

a nurse who works in the nursery is attending the vaginal delivery of a term infant, what action should the nurse complete prior to leaving the delivery room

Place the ID bands on the infant and mother

80. Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?

Place the client on fall precautions

35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

Place the implant in a lead container using long-handled forceps

405. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?

Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

515. Which intervention should the nurse implement for a client with a superficial (first degree) burn?

Place wet cloths on the burned areas for short periods of time.

525. A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result...dealing with the healthcare provider. What action should the nurse-manager implement?

Plan an interdisciplinary staff meeting to develop strategies to enhance client care

300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client?

Plan volume-controlled evenly-space meal thorough the day

296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication?

Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention

92. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Position a firm wedge to support pelvis and thorax at 30 degree tilt.

491. During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?

Prepare for the endotracheal tube to be repositioned

214. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.

Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula

482. A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important?

Prepare the client for intubation

285. A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?

Prepare the skin for procedure.

The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for?

Preparing for other diagnostic testing. The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal defects. An elevated result may be a false indicator, so other tests are indicated (B).

An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?

Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?

Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing (D) is a care delivery model that provides client care by assignment of functions or tasks. Team nursing (A) is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management (C) is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure?

Prior reaction to contrast media

280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement?

Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing

110. A client who was splashed with a chemical burn has both eyes covered with bandages. When assisting the client eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement? a) Orient the client to the location of the food on the plate b) Provide with only finger foods c) Feed the client the entire meal d) Ask family to visit during meal time to assist with feeding

Provide with only finger foods

62. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? a) Tinea corporis b) Herpes zoster c) Psoriasis d) Drug reaction

Psoriasis

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder.

363. A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

Pulse increase of 10 beats/minute

The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?

Purplish-red pinpoint lesions of the skin.

620. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin...medication?

Push the undiluted Dextrose slowly through the currently infusion IV

138. A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

Raise the head of the bed to a Fowler's position and support his arms with a pillow

27. An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to redirection, the healthcare provider prescribes restraints. Which assessment should the nurse include in the client's record while the client is in restraints? a) Pupils equal, round and reactive. b) Responsive to painful stimuli c) Speech patterns and processes d) Range -of- motion and circulation

Range -of- motion and circulation

91. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Rapid onset of decreased level of consciousness.

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Rapid onset of decreased level of consciousness.

In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A.A consistent fasting blood sugar level between 80 and 85 mg/dL B.A 2-hour postprandial level greater than 120 mg/dL C.Client reports taking a 30-minute walk after dinner D.Client describes eating pattern of four to six meals daily

Rationale: Two-hour postprandial levels greater than 120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value greater than 120 mg/dL (B) should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal (A). (C and D) are healthy behaviors for a women with gestational diabetes.

114. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider?

Reassess readiness for SNF transfer.

629. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

Rebound tenderness in the upper quadrants

The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?

Recalls drinking a glass of juice after midnight. The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications.

115. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)

Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal.

What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies?

Recognizes the value of a client's input into their own health care. Alternative and complementary therapies offer human-centered care based on philosophies that recognize the value of the client's input and honor cultural and individual beliefs, values, and desires (C).

350. When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond?

Recompress the wound suction device and secure to plug

67. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? a) Apply soft bilateral wrist restraints b) Leave the lights on in the room at night c) Redress the abdominal incision d) Replace the IV site with a smaller gauge

Redress the abdominal incision

Which interventions should the nurse include in a long-term plan of care for a client with COPD? a- Reduce risk factors for infection b- Administer high flow oxygen during sleep c- Limit fluid intake to reduce secretions d- Use diaphragmatic breathing to achieve better exhalation Reduce risk factors for infection

Reduce risk factors for infection

44. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

Reduce risks factors for infection

71. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a) Reduce risks factors for infection b) Administer high flow oxygen during sleep c) Limit fluid intake to reduce secretions d) Use diaphragmatic breathing to achieve better exhalation

Reduce risks factors for infection

Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

Reduce risks factors for infection

201. A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?

Reduced level of pain

51. A female client newly diagnosed with breast cancer is scheduled for a mastectomy next week. During the preoperative assessment, she complains that her husband has become withdrawn and complains about her irritability and frequent crying. How should the nurse respond? a) Encourage the spouse to be more supportive at this difficult time b) Refer the couple to a counselor to help them with coping strategies c) Inquire if the couple has met a minister to discuss their feelings d) Explain that a positive attitude helps reduce postoperative complications

Refer the couple to a counselor to help them with coping strategies

579. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client?

Reflection

During the physical assessment, which finding should the nurse recognize as a normal finding?

Regular pulsation at the epigastric area when the client is supine Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment.

72. A woman who is gravida 2, para 1 has been in labor for 10 hours, without an epidural or intravenous pain medication, and is now experiencing intensifying contractions that are occurring every 2 minutes. Assessment by the nurse determines that the client's cervix is 100 percent effaced and dilated 8 cm. The client is requesting intravenous nalbuphine hydrochloride (Nubain). Which action should the nurse implement? a) Administer nalbuphine hydrochloride b) Prepare client for epidural medication c) Hold medication until 9 cm dilation d) Reinforce relaxation techniques

Reinforce relaxation techniques

143. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Reinforce the importance of annual papanicolaou (Pap) smears.

122. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?

Remove cigarettes for the client's room

299. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take?

Remove the heating pads and place a soft blanket over the client's leg and feet.

58. A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

Rented movies and borrowed books to use while passing time at home

107. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

618. The nurse is preparing to discharge an older adult female client who is at risk for hy...nurse include with this client's discharge teaching?

Report any muscle twitching or seizures Take vitamin D with calcium daily Low fat yogurt is a good source of calcium Keep a diet record to monitor calcium intake

What instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Report any painful urination, blood urine, or fever

93. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?

Report any signs of cloudy urine output.

627. A client with hypertension receives a prescription for enalapril, an angiotensin...instruction should the nurse include in the medication teaching plan?

Report increased bruising of bleeding

342. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).

Report mental status change to the healthcare provider Assess the client's breath sounds and oxygen saturation Review the client's most recent serum electrolyte values

513. A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Report the client's jaw pain to the healthcare provider.

A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take?

Report the incident to the immediate supervisor.

162. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Report weight gain of 2 pounds (0.9kg) in 24 hours

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Report weight gain of 2 pounds (0.9kg) in 24 hours

153. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Reposition the client with the head of the bed elevated.

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Reposition the client with the head of the bed elevated.

316. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

Reposition the infant every 2 hours.

87. The nurse is caring for a 2-year-old male with nephritic syndrome who is receiving corticosteroid therapy. The toddler is edematous and fatigued. What nursing action is most important for the nurse to implement? a) Measure the abdominal girth twice daily b) Monitor intake and output c) Restrict sodium in the diet d) Observe for signs of Cushing's syndrome

Restrict sodium in the diet

286. Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?

Restrict unvaccinated children from attending school until measles outbreak is resolved.

195. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?

Review the client's use of over the counter (OTC) medications.

22. An older male client who was successfully treated for Herpes zoster (shingles) with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? e) Contact the healthcare provider about the need to resume the client's antiviral medication. f) Teach the client about the importance of completing the full course of antiviral medication. g) Reassure the client that the infection is resolved and the pain should soon disappear. h) Review the medication record to determine when the last analgesic was administered.

Review the medication record to determine when the last analgesic was administered.

1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream

A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?

Rubber-tipped clamps.

What are 2 primary pathogens that cause Follicilitis?

S. aureus and P. aeruginosa

When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

S1 murmur auscultated in supine position.

60. The nurse is auscultating a client's heart sounds. Which description should the nurse document this sound? http://youtu.be/1B6dUwDJ3uo http://youtu.be/g8x4NM3PuuM a. Murmur b. Pericardial friction rub c. S1 s2 s3 d. S1 s2

S1 s2 s3

When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

Schedule an appointment for an out-patient psychosocial assessment

69. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

Schedule an appointment for an out-patient psychosocial assessment.

609. A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

Schedule the client for the chest radiograph Obtain sputum for acid fast bacillus (AFB) testing Place a mask on the client until he is moved to isolation.

126. A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food selections should the nurse recommend to this client? (Select all that apply) a) Ice cream with nuts a) Fried chicken and green salad b) Scrambled eggs and potatoes c) Steamed rice and cooked squash d) Pancakes with syrup e) Pasta with a cream sauce

Scrambled eggs and potatoes Steamed rice and cooked squash Pancakes with syrup

A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

Secondary prevention (B) attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that create a suspicion of battering and domestic violence.

303. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?

Send family to the waiting area while the client's history is taking

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family members. Which action should the nurse take?

Send family to the waiting area while the client's history is taking

47. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?

Serum calcium

74. A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Serum lithium level of 1.6 mEq/L or mmol/l (SI)

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor?

Serum potassium

Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?

Supervised and guided visits with infant.

A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

Supine with the foot of the bed elevated.

Client admitted to rule out cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis?

Sweat chloride concentration of 80 mEq/L

478. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement?

Teach client to listen to music or audio books while driving

167. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?

Teach family proper range of motion exercises.

118. A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement? a) Hold the next dose of antibiotic until contacting the healthcare provider b) Teach the client how to use a dry heating pad over the painful area c) Encourage the client to practice pelvic floor exercises every hour d) Assist the client to splint the site by applying an abdominal binder

Teach the client how to use a dry heating pad over the painful area

573. A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement?

Teach the client how to use a dry heating pad over the painful area

190. A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Tell all their assigned clients to stay in their rooms.

39. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? a) Tell the UAP to offer more choices during the personal care to prevent anxiety b) Meet with the UAP later to role model more assertive communication techniques c) Assume care of the client to ensure that effective communication is maintained. d) Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

Tell the UAP to offer more choices during the personal care to prevent anxiety

The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take?

Tell the receptionist to have the healthcare provider return the phone call.

89. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response?

Temporary vasodilation

94. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor.

129. A male client is receiving ferrous sulfate, docusate sodium (Colace) and morphine sulfate. He reports that his last bowel movement was three days ago. In using the SBAR format to communicate with the healthcare provider, what recommendation should the nurse make? a) Discontinue the prescription for morphine sulfate b) An increase in the dosage of the ferrous sulfate. c) The addition of a laxative to the current regimen. d) Replace the docusate sodium with a laxative.

The addition of a laxative to the current regimen.

42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

The additive effect of multiple medications has caused the blood pressure to drop too low

467. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

The body cells develop resistance to the action of insulin.

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond?

The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record (D) should be provided. The client does not lose his legal rights to his medical record if he leaves AMA (A). The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy (B). The hospital must maintain records of the care provided and should not release the original record (C).

The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?

The child is overweight for height, so assessment of the child's daily diet (C) should be determined. The child does not need (A or B), both of which will increase the child's weight. Poor nutrition (D) is commonly seen in underweight children, not overweight.

486. A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?

The child should avoid eating homemade cookies and cupcakes during parties

A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?"

The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation.

427. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

The client has asymmetrical chest wall expansion

A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?

The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form (D).

33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply)

The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure

596. A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?

The client will be restricted from eating seafood

160. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

The client's need for pain medication should be determined.

223. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?

The client's previous GCS score

The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A) Review the medications the client is receiving B) Increase the formula infusion rate C) Increase the amount of water used to flush the tube D) Attach a rectal bag to protect the skin

The correct answer is A: Review the medications the client is receiving

The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? A) 3 episodes of vomiting in 1 hour B) Periodic crying and irritability C) Vigorous sucking on a pacifier D) No measurable voiding in 4 hours

The correct answer is D: No measurable voiding in 4 hours

416. A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

The family reports a great reduction in client's maniac behavior

39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?

The gallbladder is normal

619. The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information?

The husband cannot sign the consent for the client, her signature is required The client's specific wishes should be discussed with her healthcare provider The healthcare team will formulate a plan of care to keep the client comfortable

A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide?

The infection has walled off into an area of infected bone creating a barrier to antibiotics. A sequestrum (dead bone) is separated from the living bone and has no blood supply, so neither antibiotics nor white blood cells can reach the infected area (D). (A and B) do not address the encasement of the necrotic tissue. Although a sinus tract may occur, (C) does not address the purpose of the surgery.

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperreflexia (autonomic dysreflexia)? - The injury results in loss of the reflex arc- The injury is above the 6th thoracic vertebra- There has been a partial transection of the cord- There is a flaccid paralysis of the lower extremities

The injury is above the 6th thoracic vertebra-

508. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease.

myxedema

The patient with myxedema coma should be admitted to the intensive care unit, and hypovolemia and electrolyte abnormalities corrected. Mechanical ventilation may be necessary. Cardiovascular status should be monitored carefully, especially after intravenous thyroid hormone replacement

48. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

The technique is intended to maintain straight spinal alignment.

111. The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink popular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. What explanation should the nurse offer? a) This rash is characteristic of a medication reaction b) This is a common newborn rash that will resolve after several days c) The rash is due to distended oil glands that will resolve in a few weeks d) The healthcare provider is being notified about the rash

This is a common newborn rash that will resolve after several days

38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?

To reduce abdominal pressure on the diaphragm

Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?

Tolerance of exertion.

446. The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?

Too much salt can cause the kidneys to retain fluid

333. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)

Topical corticosteroid. Oral antihistamine

362. A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?

Tracheal deviation toward the left lung.

157. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?

Transfer the client to the surgical floor.

493. A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?

Turkey salad sandwich.

24. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone (Narcan)? a) Complaints of increasing flank pain b) Statements about visual hallucinations c) Respiratory rate of 12 breaths/minute d) Unresponsive to verbal or tactile stimuli

Unresponsive to verbal or tactile stimuli

The nurse plans to collect a 24 hour urine specimen for a creatine clearance test. What information does the nurse need to provide?

Urinate at a specified time, discard the urine, and collect all subsequent urine during the next 24 hours.

207. The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.

616. A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour

12. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? a) Blood pressure 170/98 b) Joint and muscle aches c) Urine output 300 ml/hr d) Dark, rust-colored urine

Urine output 300 ml/hr

35. A client in septic shock has a double lumen central venous catheter with one liter of 0.9Normal Saline solution at 100 mL/hour through one lumen and Total Parenteral Nutrition (TPN) infusing at 50 mL/ hour through one port. The nurse prepares a newly prescribed IV antibiotic that should take 45 minutes to infuse. What intervention should the nurse implement? a) Use as secondary port of the Normal Saline solution to administer the antibiotic b) Add the antibiotic to the Normal Saline solution and continue both infusions c) Add the antibiotic to the TPN solution, and continue the normal saline solution d) Stop the TPN infusion for the time needed to administer the prescribed antibiotic. %

Use as secondary port of the Normal Saline solution to administer the antibiotic

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.)

Use lanolin to moisturize the tops and bottoms of the feet. Wash feet daily and dry well, particularly between the toes. Wear leather shoes that fit properly.

131. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Use sunblock or protective clothing when outdoors.

72. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client?

Use two forms of contraception while taking this drug.

Causes of Endocarditis

Usually caused by a bacteria Recent dental/ oropharyngeal surgery prolonged use of IV catheters or TPN Burns Hemodylasis rheumatic heart disease congenital heart disease IV drug abuse Cardiac surgery Immunosuppression dental procedures invasive procedures

Prior to a cardiac catheterization, which activity should the nurse have the client practice?

Valsalva's maneuver and coughing.

145. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias.

132. A nurse is planning a class for a group of 18 adults recently diagnosed with the Type 2 DM. Included in the class content is blood glucose monitoring (BGM). Which teaching strategies are best for the NURSE to use with this group? a) Lecture followed by a question and answer session. b) Distribution of pamphlets on BGH with a follow up quiz c) Small group discussing with a packet of the BGM supplies d) Video presentation followed by a demonstration.

Video presentation followed by a demonstration.

397. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include?

Wear long sleeves and pants

The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?

Wear the brace over a T-shirt 23 hours per day. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace.

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan?

Weigh every morning

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.

172. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.

69. When planning care for a female client recently diagnosed with anorexia nervosa, which intervention is most important for the nurse to include in the plan of care? a) Weight the client daily at the same time using the same scale b) Encourage the client to talk about her sources of anxiety c) Document daily nutritional intake and record daily output d) Monitor the client's complete blood count at least weekly

Weight the client daily at the same time using the same scale

7. The nurse weighs a 6-month-old infant during a well baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? a) What food does your baby usually eat in a normal day? b) What was the baby's weight at the last well-baby clinic visit? c) The baby is below the normal percentile for weight gain d) Your baby is gaining weight right on schedule

What food does your baby usually eat in a normal day?

The nurse is assessing a client's nailbeds.

Which appearance indicates further follow-up is needed for problems associated with chronic hypoxia. clubbing

115. A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? a) Review the surgical consent with the client b) Explain that vomiting can occur during surgery c) Remove the food from the client d) Withhold the preoperative medication

Withhold the preoperative medication

182. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?

Yogurt and/or buttermilk.

85. The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Yogurt and/or buttermilk.

499. When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat?

Yogurt. Processed cheese.

Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?

You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?

A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings?

Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive

533. An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?

Your blood pressure is a little high. You need to have it rechecked within one week

A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

a

A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? A.)Nausea and indigestion .B.)Hypersalivation C.)Eyelid and facial twitching D.)Increased appetite

a

A multigravida client arrives at the L&D unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal HR is between 140 and 150 beats/min. What action should the nurse implement next? A. complete sterile vag exam B. take maternal temp every 2 hrs C. Prepare for an immediate cesarean bitrh D. Obtain sterile suction equipment

a

A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to this child's mother? A. Place padding on the corners of all furniture. < B. Give the child only one baby aspirin for pain relief. C. Ensure that dental hygiene is done frequently. D. Do not allow the child run inside the house.

a

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A.)Initiate the dosage lockout mechanism on the PCA pump B.)Instruct the client to use the medication before the pain becomes severe C.)Assess the abdomen for bowel sounds. D.)Assess the client ability to use a numeric pain scale

a

5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago receiving heated mist c) Subdural hematoma with an intracranial monitoring device d) Acute coronary syndrome treated with vasopressors

a) Diabetic ketoacidosis and titrated IV insulin infusion

31. A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) a) Graves disease, an autoimmune condition, affects thyroid stimulating hormone receptors. b) T3 and T4 hormone levels are increased c) Large protruding eyeballs are a sign of hyperthyroid function d) Weight gain is a common complaint in hyperthyroidism e) Early treatment includes levothyroxine (Synthroid).

a) Graves disease, an autoimmune condition, affects thyroid stimulating hormone receptors. b) T3 and T4 hormone levels are increased c) Large protruding eyeballs are a sign of hyperthyroid function

70. AN adolescent boy who is attending summer camp becomes ill. His immunizations record indicated that he did not receive the HA vaccine (HAV). After receiving the confirmed diagnosis of Hepatitis A (HA), in which priority should the camp nurse take action? (Arrange in sequence from highest to lowest priority). a) Review all campers record for history of HA vaccine immunization b) Monitor all campers without HAV for signs of illness c) Notify all parents of each camper's possible exposure d) Review health department protocols for reporting incidents of HA

a) Review all campers record for history of HA vaccine immunization b) Monitor all campers without HAV for signs of illness c) Notify all parents of each camper's possible exposure d) Review health department protocols for reporting incidents of HA

15. A client develops urticaria on the trunk and neck shortly after a secondary infusion of pipercillin (Zosyn) is initiated. In what order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.) a) Stop the infusion b) Assess vital signs c) Contact the healthcare provider d) Document reaction to the drug e) Initiate an adverse event report

a) Stop the infusion b) Assess vital signs c) Contact the healthcare provider d) Document reaction to the drug e) Initiate an adverse event report

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has astage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply. a. Disposable gown b. Face shield c. Gloves d. N95 Respirator e. Surgical mask

a, b, c, e Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza)are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets (Option 5).Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care)

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin Aspart q6h are prescribed. What action should the nurse include in this client‟s plan of care? a- Fingerstick glucose assessment q6h with meals b- b- Mix bedtime dose of insulin glargine with insulin aspartsliding scale dose c- c- Review with the client proper foot care and prevention of injury d- d- Do not contaminate the insulin aspart so that it is available for iv use e- e- Coordinate carbohydrate controlled meals at consistent times and intervals f- f- Teach subcutaneous injection technique, site rotation and insulin management

a,c,e,f

A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

a- Administer a PPD test ***b- Schedule the client for the chest radiograph ***c- Obtain sputum for acid fast bacillus (AFB) testing ***d- Place a mask on the client until he is moved to isolation. e- Send the client home with instructions for a prescribe antibiotic. BCD Rationale: Client with history of TB a chest x-ray and sputum are indicated. The client sign and symptoms indicate the pt should wear mask to protect others.

After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?

a- An older adult who is unable to communicate elimination needs. ***b- An older man whose sheets are damped each time he is turned. c- A woman with osteoporosis who is unable to bear weight. d- A poorly nourished client who requires liquid supplement. a Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

a- Chest physiotherapy should be performed twice a day before a meal.

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

a- Collect a clean catch urine specimen. b- b- Instruct the client to empty the bladder. ***c- c- Obtain vital signs and breath sounds. d- d- No specific nursing action is required Rational: the client‟s baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminating. Other options would not assure a safe administration of the medication. Abused female-assess

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

a- Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

a- Encourage the parents to stay at the bedside b- Use distraction techniques to reduce pain. ***c- Maintain strict aseptic technique d- Place a drape over the pubic area.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one-day kill her, she keeps hoping that he will change. What action should the nurse take first?

a- Report the finding to the police department b- Discuss treatment options for abusive partners c- Determine the frequency and type of client‟s abuse ***d- Explore client‟s readiness to discuss the situation.

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: a- Restlessness c- Increased pulse rated- b.Increased respiratory rate. d. ncreased temperaturef- e.Peripheral pallor of the skin

a- Restlessness c- Increased pulse rated- b.Increased respiratory rate.

The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? a- Yogurt and/or buttermilk. b- Avocados and cheese c- Green leafy vegetables d- Fresh fruits

a- Yogurt and/or buttermilk.

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

a. An adult female who has been depress for the past several months and denies suicidal ideations. b. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. ***c. A young male with schizophrenia who said voices is telling him to kill his psychiatric. d. An elderly male who tell the staff and other client that he is superman and he can fly. A young male with schizophrenia who said voices is telling him to kill his psychiatric

To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

a. Dress each wound separately. b. Avoid sharing equipment between multiple clients. c. Use gown, mask and gloves with dressing change. d. Implement protective isolation. ****Dress each wound separately. Rational: each wound should be dressed separately using a new pair of sterile glove to avoid auto contamination (the transfer of microorganisms' from one infected wound to a non-infected wound). The other choices do not prevent auto contamination.

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care

a. Encourage Progressive active range of motion ***b. Teach need for dietary and supplementary vitamin D3 c. Explain the need for skin exposure to sunlight without sunscreen d. Instruct the client to use of muscle strengthening exercises

During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)

a. Encourage the woman at risk for cancer to obtain colonoscopy. b. Present a class of breast-self examination ***c. Prepare a woman for a bone density screening d. Explain the follow-up need it for a client with prehypertension. Prepare a woman for a bone density screening

55. An infant who is admitted to the newborn nursery has facial features that are commonly observed in newborns with Down syndrome. Which additional finding should the nurse identify? a. Flat occipital bone b. High pitch shrill cry c. Cranial suture fusion d. Hypoplasia of maxillae

a. Flat occipital bone

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?

a. Obtain a prescription for an anticholinergic medication b. Determine how many hours declined slept last night c. Administer the PRN prescription for severe anxiety d. Watch the thyroid cartilage move while the client swallows Obtain a prescription for an anticholinergic medication Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?

a. Perform CPT after meals to increase appetite and improve food intake. ***b. CPT should be performed more frequently, but at least an hour before meals. c. Stop using CPT during the daytime until the child has regained an appetite. d. Perform CPT only in the morning, but increase frequency when appetite improves.

While caring for a 9 year old with acute glomerulonephritis the nurse knows which clinical assessment finding is priority to monitor?

a. Proteinuria b. Urine output ***c. Blood pressure d. Daily weight measurements

93. Skeletal traction is applied to the affected leg of a client with compound fracture to the tibia and fibula. Which intervention is most important for the nurse to include in the client's plan of care? a) Teach divisional activities while in traction b) Reinforce the need for bed rest exercises c) Encourage family to participate in care d) Assess and provide routine pin care

assess and provide routine pin care

585. In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents?

avoid smoking in the house

A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend? a. Eat food high in garlic with the evening meal b. Drink chamomile tea at breakfast and in the evening. c. Increase cocoa in the diet and drink before bedtime d. Join a yoga class that meets at least weekly

b

A client is admitted to the coronary intensive care unit with a diagnosed acute heart failure (HF) and myocardial infarction (MI). Which medication would the nurse anticipate the healthcare provider to prescribed to the client to decrease the preload and afterload, slow down their respirations, and reduce their anxiety and pain due to the MI?a. Enalapril (Vasotec). b. Morphine sulfate (Contin, MSIR). c. Hydrochlorothiazide (HCTZ, Urozide). d. Diazepam (Valium, Diastat,

b

A client who had a vaginal hysterectomy the previous day is saturating perineal pads with blood and requires frequent changes during the night. What priority action should the nurse take? A. Provide iron-rich foods on each dietary tray. B. Monitor the client's vital signs every 2 hours. C. Administer IV fluids at the prescribed rate. D. Encourage postoperative leg exercises.

b

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

b

After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take?' A. Replace the empty tank without reporting the situation to any members of the agency. B. Complete an adverse occurrence report and submit it to the nurse-manager. Correct C. Send an anonymous letter explaining the situation to the family of the client. D. Advise the flight crew of the situation, then suggest that no further discussion be held.

b

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness

b

The home care nurse visits a patient with chronic heart failure. Which clinical manifestations, assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? a. Fatigue, orthopnea, and dependent edema b. Severe dyspnea and blood-streaked, frothy sputum c. Temperature is 100.4oF and d.pulse is 102 beats/mind. Respirations 26 breaths/min despite oxygen by nasal cannula

b

The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia? A) Must have structured activities B) Often take part in active sports C) Explain limitations to peer groups D) Avoid risks after bleeding episodes

b

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? a- Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. b- Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie. c- Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream pie. d- Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie.

b

To assess a client with meningitis for meningeal irritation, how should the nurse position the client's head? A. The neck and head are twisted toward the shoulder. B. The head and neck are flexed toward the chest. < C. The ear is flexed downward toward the shoulder. D. The head and neck are extended toward the back.

b

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP turn the patient to the right side. d. UAP place an emesis basin at the bedside

b

6. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? a) Beta blockers b) Bronchodilators c) Corticosteroids d) Beta-adrenergics

b) Bronchodilators

4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? a) Presence of bruising, weakness, or fatigue b) Therapeutic exercise included in daily routine. c) Average amount of protein eaten daily d) Existence of gastrointestinal discomfort

b) Therapeutic exercise included in daily routine.

The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.) A. White bread B. Salmon C.Broccoli D. Whole milk E. Banana

b,c,e

fracture hematoma

blood clot that forms at the site of a broken bone

.A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

c

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? A: "You do not have to tell him because this is not a reportable disease." B: "Because there is no cure for this disease, telling him is of no benefit to him or to you." C: "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." D: "You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease."

c

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain

c

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a- Review the heart rhythm on cardiac monitors b- Check urinary catheter for obstruction c- Auscultated bilateral breath sounds a- Give PRN dose of lorazepam (Ativan)

c

A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions moximizes the effectiveness of incentive spirometry? a) side-lying b) supine c) semi-fowler's d) trandelenburg

c

A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? a. Perform a bladder scan to assess for urinary retention. b. Restrict the patient's oral fluid intake to 500 mL per day. c. Assist the patient to a sitting position with arms on the over bed table. d. Instruct the patient to use pursed-lip breathing until the dyspnea subsides

c

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? a- Administer PRN medication b- Titrate the oxygen to keep saturation above 92% c- Hold oral intake until swallow evaluation is done. d- Elevate the head of his bed at least 45 degrees.

c

An adult female client is admitted to the psychiatric unit because of a complex handwashing that takes two hours or longer to complete. She worries about staying clean and refuses to sit...client‟s handwashing is an example of which clinical behavior? a. Addiction b. Phobia c. Compulsion d. Obsession

c

Incentive spirometer video, they are blowing into it. answer was slowly to breathe in

c

The nurse is assessing a 12 year-old who has Hemophilia A. Which finding would the nurse anticipate? A) An excess of red blood cells B) An excess of white blood cells C) A deficiency of clotting factor VIII D) A deficiency of clotting factors VIII and IX

c

The nurse knows that which statement is accurate for enoxaparin [Lovenox]? a It equally reduces the activity of thrombin and factor X a. b It has selective inhibition of factor Xa and no effect on thrombin. c It reduces the activity of factor Xa more than the activity of thrombin. ' d It has a lower bioavailability and shorter half-life than unfractionated hepa

c It reduces the activity of factor Xa more than the activity of thrombin. '

1. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a) Ensure that the restraints are snug against the client's wrists. b) Move the ties so the restraints are secured to the side rails. c) Ensure that the knot can be quickly released. d) Tie the knot with a double turn or square knot.

c) Ensure that the knot can be quickly released.

When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? SATA a. Canned fruit cocktail b. Creamy peanut butter c. Vegetable juice d. Vanilla frozen yogurt e. Clear beef broth

c,d,e

A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration?

c. Inspire deeply and slowly over 3 to 5 seconds

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? (Trousseau's) a. Ask the UAP to take the blood pressure in the other arm b. Tell the UAP to use a different sphygmomanometer. d. Administer PRN antianxiety medication.

c. Review the client's serum calcium level

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? a. Elevate the hands on two pillows at night b. Notify the healthcare provider as soon as possible c. Wear braces as both wriSts during the night d. Apply cold compresses for 30 min before bedtime

c. Wear braces as both wriSts during the night

What should the nurse do after a medication error has occurred and the patient's safety has been assured?

contact HCP and nurse manager

How is folliculitis transmitted?

contact between person to person fomites

78. The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

corner of mouth to ear

A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?

creatinine clearance 25 mL/ minute

A client with hemophilia has a very swollen knee after falling from bicycle riding. Which of the following is the first nursing action? a)initiate an IV site to begin administration of cryoprecipitate b) type and cross-match for possible transfusion c) monitor the client's vital signs for the first 5 minutes d) apply ice pack and compression dressings to the knee

d

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? a- "Is there a history of female baldness in your family?" b- "Are you under any unusual stress at home or work?" c- "Do you work with hazardous chemicals?" d- "Have you noticed any changes in your fingernails?"

d

After assessing an older with a suspected cerebrovascular accident (CVA), the nurse documents the client ́s right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, the clients neurological assessment remains unchanged. Which action should the nurse implement first? a- Administer an oral analgesic with antiemetic b- Collect blood for coagulation times c- Send the client for a computed tomography scan the brain d- Obtain a history of medication use, recent surgery, or injury

d

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a. Tell the client that the vaccine for HPV is not indicated b. Inform the client that warts do not return following cryotherapy c. Recommended the use of latex condoms to prevent HPV transmission. d. Reinforce the importance of annual papanicolaou (Pap) smears.

d

The nurse is assigning rooms for four clients, each newly diagnosed and being admitted to the acute neuro unit for treatment. The client with which diagnosis should be assigned the only private room available? A. Viral encephalitis. B. Septic shock. C. Brain abscess. D. Bacterial meningitis. <

d

The nurse recognizes that compliance with ART regimens is often problematic for patients. What level of compliance is needed to help ensure ongoing success with this therapy? A) 50% B) 65% C) 80% D) 95%

d

When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? A. A sluggish blood return. B. Client uses the arm cautiously. C. Spot of dried blood at insertion site. D. Red streak tracking of the vein.

d

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan that increases the risk for cervical cancer? A: Neisseria gonorrhoea.' B: Chlamydia trachomatis.' C: Herpes simplex virus. D: Human papillomavirus.

d

While caring for a client with infective endocarditis, the nurse must be alert for signsof pulmonary embolism. Which of the following assessment findings suggests this complication? A) Positive Homan's sign B) Fever and chills C) Dyspnea and cough D) Sensory impairment

d

the nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? a- Limit intake fatty foods for one month after surgery. b- Notify the healthcare provider if edema occurs. c- Increase activity and exercise gradually, as tolerated. d.Avoid crowds for first two months after surgery

d

3. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? a) Lip smacking and frequent eye blinking b) Shuffling gait and stooped posture c) Rocks back and forth in the chair d) Muscle spasms of the back and neck

d) Muscle spasms of the back and neck

2. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client? a) Doubt b) Observation c) Confrontation d) Reflection

d) Reflection

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client requests an afternoon snack, which dietary choice should the nurse provide? a- Vanilla-flavored yogurt b- Low fat chocolate milk. c- Calcium fortified juice d- Cinnamon applesauce

d- Cinnamon applesauce Ciprofloxacin shouldnt be taken with alkaline foods/drugs (milk, dairy, antacids, sodum bicarb), magnesium, calcium, iron, and aluminum products should be taken 2 hours before, or 6 hr after cipro oral.

Meniere's disease

disorder of inner ear causing vertigo, tinnitus, and hearing loss

Assess for and report signs/symptoms of cardiac dysrhythmias (

e.g. irregular apical pulse, adult pulse rate below 60 or above 100 beats/minute, apical-radial pulse deficit, syncope, palpitations). Reduce cardiac workload Position patient to minimizes discomfort and facilitate respiration. Minimize anxiety with calm reassurance and education. Communicate rationale for monitoring and treatments. Discuss the benefits calm with the patient and family.

peptic ulcer s/s

gnawing pain dyspepsia heartburn nausea vomiting

420. The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?

headache, photophobia, and nuchal rigidity

95. The healthcare provider prescribes methylergonvine maleate (Methergine) for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the mediation? a) Difficulty locating the uterine fundus b) Hypertension c) Saturation of more than one pad per hour d) Excessive lochia

hypertension

415. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?

infectious process

Folliculitis

inflammation of the hair follicles

17. Sublingual nitroglycerin is administered to a male client with instable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40. Which intervention should the nurse implement? a) Give a PRN antiemetic medication b) Infuse a rapid IV normal saline bolus c) Begin external chest compressions d) Administer second dose of nitroglycerin

infuse a rapid IV normal saline bolus

A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? i- Review record of recent analgesia j- Provide frequent pulmonary toilet k- Prepare the client for intubation l- Obtain STAT arterial blood gases

k

421. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

nausea and projectile vomit

when to give lantus

night

Multiple drug interactions and potentiation of medications such as anticonvulsants and anti anxiety drugs have been reported with the concomitant use of kava kava. - T

reats anxiety - Hepatotoxic - Increases the effect of benzodiazepines - Inhibits the effects of levodopa in pts w/ Parkinson disease - -induce psychiatric symptoms - -liver failure Cause excessive sedation,

Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client

reports decrease in pain.

papilledema

swelling of the optic disc

141. A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this clients plan of care? a) restrict daily fluid intake by 1500 ml b) maintain accurate intake and output c) weigh client every morning d) administer prescribed diuretic

weigh client every morning

A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?

you need to seek immediate medical assistance to evaluate the cause of these symptoms

The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (UAP)?

•***Assisting the patient with oral hygiene•Observing the patient's response to feedings•Facilitating expression of grief or anxiety•Initiating daily weights

Gastric peptic ulcer ss

▪ Gnawing, sharp pain in or to the left of the midepigastric region occurs 30 to 60 minutes after a meal (food ingestion accentuates the pain). ▪ Hematemesis is more common than melena.

354. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?

"After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

***a- Inspect skin for redness ***b- Use a residual limb shrinker c- Apply alcohol to the stump after bathing ***d- Wash the stump with soap and water e- Avoid range of motion exercises

A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterization in 2 days. Which questions is the priority for the nurse to ask?

"Do you know if you're allergic to iodine?"

147. A female college student is brought to the Emergency Department by her roommates who report that she was brought home about 4 hours ago by a group of fraternity brothers who reported that she was drunk. Her friends tell the nurse that when she began to awaken she stated, "I can't believe I let them do that to me. I should have resisted. It was my fault it happened. I was so stupid." How should the nurse respond? a) "Do you think the boys had reason to believe they could take advantage if you?" b) "Do you remember what you had to drink last night?" c) "DID you know the boys who brought you home last night?" d) "I am sorry you made some bad choices in terms of your safety."

"Do you remember what you had to drink last night?"

626. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother...During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide?

"His smaller size is probably due to the heart disease"

523. The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis?

"I couldn't get my son's socks and shoes on this morning"

14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication?

"I have a headache that gets worse when I sit up"

The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy?

"I will keep the baby's eyes covered when the baby is under the light." Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infant's eyes should be protected (C) by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not (A), so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose as much skin as possible to the light (D).

A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?

"Tell me about your undergarments so we can discuss how you can have your examination comfortably.

64. A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond?

"The heart will stop beating & you will stop breathing."

A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?

"To protect you because you can get an infection very easily."

29. While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? a) "How old do you think I am?" b) "We need to stay focused on the topic." c) "I think I am qualified to teach this group." d) "Do you think you can teach it any better?"

"We need to stay focused on the topic."

519. The nurse is conducting the initial assessment of an ill client who is from another culture.... What response should the nurse provide?

"What practices do you believe will help you heal?"

77. While the nurse is taking a health history, the client announces, I don't have time for this. This is a waste of time. I need treatment" Which response is best for the nurse to provide? a) Ignore the angry outburst and continue with the history questions b) "You sound angry. Would you like to tell me about it?" c) Move closer and place a hand on his shoulder to demonstrate concern. d) "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

"You sound angry. Would you like to tell me about it?"

1. Chest tube - evaluate Collection chamber

(Middle column)

32. The nurse is (caring?) a client with nasogastric (NG) tube. Which task (can the nurse delegate to the unlicensed assistive personnel (UAP)??) e) (Secure?) the NG tube if it (slides?)out of the client's nasal passage f) (Replace?) the NG tube as prescribed by the healthcare provider g) Disconnect the NG tube suction so the client can ambulate in the hallway h) Reconnect the NG suction when the suction when the client returns from ambulating

(Secure?) the NG tube if it (slides?)out of the client's nasal passage

Which instructions should the nurse provide related to the bronchoscopy? (Select all that apply.)

***"You must not eat or drink anything for 6 to 8 hour prior to the procedure." ***"You will receive a medication to dry up secretions and another medication to make you sleepy." ***"The oral and nasal pharynx will be sprayed with a local anesthetic."

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours.Which finding should the nurse report immediately to the healthcare provider?

***1 Confusion and tremors 2 Yellowing and itching of skin 3. Abdominal pain and vomiting 4. Anorexia and abdominal distention

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first?

***1 Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34-38 breaths/min 2 Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain 3 Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography (ERCP) 4Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

***1. Withhold food and fluid intake. 2. Initiate IV fluid replacement. 3. Administer antiemetic as needed. 4. Evaluate intake and output ratio. Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management.

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

***a- Monitor heart, lung, and kidney function. ***b- Notify healthcare provider of serum amylase and lipase levels. c- Position client on abdomen to provide organ stability d- Encourage an increased intake of clear oral fluids ***e- Review client's abdominal ultrasound findings. ABE

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

***a. Inspect skin for redness ***b. Use a residual limb shrinker c. Apply alcohol to the stump after bathing ***d. Wash the stump with soap and water e. Avoid range of motion exercises ABD

A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

***a. Negative pressure environment b. Contact precautions c. Droplet precautions d. Protective environment

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

***a. Reposition the client with the head of the bed elevated. b. Commend the UAP for implementing the proper position c. Tell the UAP that this position is harmful to the client d. Encourage the child to ambulate in the room

Which food would be most appropriate for a patient who recently had a bout of acute pancreatitis? SATA

- Fried chicken - Potato chips - ***Grilled chicken and a baked potato - ***Reduced fat cheese and whole wheat crackers Whole milk with cookies

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

. Blood pressure fluctuations means that the condition has become chronic ****B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

. Reposition the client in a side-lying position and support his abdomen with pillows. b. Elevate the client's feet on a pillow while keeping the head of the bed elevated. ***c. Raise the head of the bed to a Fowler's position and support his arms with a pillow Place the client in a shock position and monitor his vital signs at frequent intervals *****Raise the head of the bed to a Fowler's position and support his arms with a pillow

Widening pulse pressure

...an increase in systolic with concurrent decrease in diastolic blood pressure; an indication of increased ICP

625. The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide?

.Move the device one to two inches away from the mouth

455. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?

.creatinine clearance 25 mL/ minute

40. An adolescent receives a prescription for an injection of sumatriptan (Imitrex) 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.)

0.33 mL

346. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

0.4

437. A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).

0.4

27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)

0.4 ml

41. An infant who weighs 22 lbs. is to receive 15 mcg/kg of a medication. How many ml should the nurse administer if the medication is available in 1 mg/ 5 ml? Round to the nearest hundredth?

0.75

68. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? a) 0.9 %sodium chloride solution (normal saline) b) 0.45% sodium chloride solution (half normal saline) c) 10% Dextrose in 0.45% sodium chloride d) 5% dextrose in 0.2% sodium chloride %

0.9 %sodium chloride solution (normal saline)

418. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution?

0.9% sodium chloride solution (normal saline)

38. A nurse is caring for a client who is postoperative following an appendectomy and is receiving gentamicin. Which of the following assessment findings should the nurse identify as an adverse effect of this medication? 1. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity 2. Respiratory rate 22/min 3. 2+ pitting edema of the ankles 4. Hgb 8.7 g/dL

1

A client with acute pancreatitis continues to be unable to eat 48 hours after onset of the illness. The nurse notifies the provider to discuss which intervention to provide nutrition for this client?

1 A clear, fortified liquid diet 2 Gastric tube feedings ***3 Jejunal tube feedings 4 Total parenteral nutrition (TPN)

What diet does the health care provider prescribe for a client during the healing phase of acute pancreatitis? Select all that apply.

1 Alcohol ***2 High protein ***3 Low fat meal 4 Coffee and tea ***5 High carbohydrates

Which is a priority nursing assessment for the client with severe acute pancreatitis?

1 Breath sounds and other signs of pneumonia 2 Fever and other signs of infection 3 Pain level and other signs of discomfort ***4 Perfusion and other signs of shock

Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?

1.5 mL.

A client is diagnosed with acute pancreatitis. Which test is a sensitive indicator of biliary obstruction in this disorder?

1 Serum bilirubin 2 Alkaline phosphatase 3 Serum amylase ***4 Serum alanine aminotransferase

A client who has acute pancreatitis is ordered to receive ranitidine (Zantac). The nurse explains that this drug is given for which purpose?

1 To alleviate pain caused by the release of pancreatic enzymes ***2 To decrease gastric acid secretion that often occurs with pancreatitis 3 To improve the client's ability to absorb food as the disease is resolving 4 To minimize the side effects of other medications used to treat pancreatitis

Which symptoms manifested by a client with acute pancreatitis indicate complications? Select all that apply

1 Vertigo ***2 Jaundice 3 Depression ***4 Darkened urine ***5 Clay-colored stools

nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider?

1) Blood-tinged sputum 2) Dry, nonproductive cough 3) Sore throat ***4) Bronchospasms Correct Bronchospasms

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. 1.Contact the surgeon. 2.Instruct the client to remain quiet 3.Prepare the client for wound closure. 4.Document the findings and actions taken 5.Place a sterile saline dressing and ice packs over the wound. 6.Place the client in a supine position without a pillow under the head.

1,2,3,4

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply. 1. Apply cool, moist washcloths to the affected areas 2. Keep the fingernails trimmed short to minimize skin scratching 3. Take a hot bath or shower to alleviate itching sensations 4. Use skin protectant or moisturizing cream over unbroken skin 5. Wear cotton gloves or long-sleeved clothing to avoid scratching

1,2,4,5

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply. 1 Heparin 2 Clopidogrel 3 Warfarin 4 Enoxaparin 5 Acetylsalicylic acid

1,4

98. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom)

1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia

540. A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last)

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

521. The nurse is collecting a sterile urine specimen using a straight catheter tray for culture.... (Arrange from first action to last).

1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus

334. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.)

1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

365. Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom)

1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

212. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)

1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia

372. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom)

1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital's chief of medical services. 5. File a formal complaint with the state medical board.

109. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opiod-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9

440. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9

The LPN/LVN in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

1.Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix)

For care of a patient who has oral cancer, which task would be appropriate to assign to an LPN/LVN?

1.Assisting the patient to perform oral hygiene• 2.Explaining when brushing and flossing are contraindicated• ***3.Giving antacids and sucralfate suspension as ordered• 4.Recommending saliva substitutes

428. A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

1000 units/hour

310. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)

12.5

21. The healthcare provider prescribes an IV solution of Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 ml for a client with unstable angina who weighs 60 kg. After administering the loading dose, the nurse initiates the infusion at 12 units/kg/hour per protocol. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the whole number.)

14 mL/hr

560. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only).

18

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. "I should not exercise since I am taking insulin." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "NPH is a basal insulin, so I should exercise in the evening."

2

A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following? 1. Nicotine withdrawal 2. Heroin intoxication 3. Alcohol withdrawal 4. Amphetamine intoxication

2

The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 1. increased pulse rate. 2. decreased temperature. 3. fine tremors. 4. increased radioactive iodine uptake level.:

2

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?'1. Lack of knowledge' 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

2

Famotidine 20 mg IVBP is prescribed for a client with a duodenal ulcer. The medication is diluted in 50 mL of 5% dextrose and is to infuse over 15 minutes. At what rate should the infusion control device be set. Record your answer using a whole number.

200 mL/hr

A patient with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the patient use to prevent skin breakdown? Select all that apply. 1. Avoid lotions containing calamine. 2. Add baking soda to the water in a tub bath. 3. Keep nails short and clean. 4. Rub the skin when it itches with knuckles instead of nails. 5. Massage skin with alcohol. 6. Increase sodium intake in diet.

2,3,

561. The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2,500

A client eats a meal that contains 13 g of fat, 31 g of carbs, and 5 g of protein. What is the client's total caloric intake for this meal?

261 calories

105. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only).

20

Dopamine (Intropin), 5 mcg/kg/min, is prescribed for a client who weighs 105 kg. The nurse mixes 400 mg of dopamine in 250 mL D5W for IV administration via an infusion pump. What is the hourly rate that the nurse should set on the pump?

20 mL/hr

430. The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis?

20 pack-year history of cigarette smoking

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101 °F (38.3 °C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

3

219. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

36 %

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

36%

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously

4

575. The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

45

607. Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

47

128. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI)? (Click the chose location).

5th intercostal space

A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

61 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour

402. A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

7

559. A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour...verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving?

700

24. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

75 ml/hour

297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

8

A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by explaining that: a. The pain is a normal, temporary condition b. The pain occurs because nerves have been cut c. This pain will go away once a prosthesis is used d. Pain medication may be needed for life to alleviate the discomfort

A

When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? A.Speak privately with the nurse. B.Hold a staff meeting to discuss this issue. C.Review the nurse's current salary. D.Nominate the nurse for employee of the month.

A The nurse-manager should speak privately with the nurse (A) to assess the nurse's motives and to discuss allowing other team members the opportunity to be on call for the day shift. (B) might become confrontational. (C) is irrelevant. (D) is not warranted.

457. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?

A 10-year-old who is receiving chemotherapy and the infusion pump is beeping

The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?

A Buretrol attachment.

45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?

A business and professional women's group.

123. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)

A client must be willing to accept palliative care, not curative care. The healthcare provider must project that the client has 6 months or less to live.

381. A nurse working on an endocrine unit should see which client first?

A client taking corticosteroids who has become disoriented in the last two hours.

501. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has

A collapsed lung

Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication?

A common side effect of antipsychotic medications is constipation, and increasing high-fiber foods in the diet (A) can help to alleviate this problem.

125. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

A mother with an infected episiotomy

A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?

A nurse with Marfan's syndrome who is postmenopausal.

120. A client had a subtotal parathyroidectomy two days ago, and is now preparing for discharge. Which assessment finding is most important for the nurse to provide to the healthcare provider prior to client discharge? a) Afebrile with a normal pulse b) No bowel movement since surgery c) No appetite for breakfast d) A positive Chvostek's sign

A positive Chvostek's sign

The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?

A pregnant woman.

Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio?

A self-evaluation that identifies how the nurse has met professional objectives and goals.

A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid?

A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet.

464. After teaching a male client with chronic kidney disease (CKD) about therapeutic diet...which menu of foods indicates that the teaching was effective? Select all that apply

A slice of whole grain toast A bowl of cream of wheat

183. The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

A young male with schizophrenia who said voices is telling him to kill his psychiatric.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A) "How will this affect your present sexual activity?" B) "How active is your current sex life?" C) "How has your sex life changed as you have become older?" D) "Tell me about your sexual needs as an older adult."

A) "How will this affect your present sexual activity?" - (A) offers an open-ended question most relevant to the client's statement. (B) does not offer the client the opportunity to express concerns. (C and D) are even less relevant to the client's statement.

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. A) "I have ringing in my ears." B) "It improves when I lie down." C) "Bright lights really bother my eyes." D) "It gets better as soon as I walk a while." E) "My head hurts more when I am sitting watching tv." F) My head hurts more when I am lying on my side breastfeeding."

A) "I have ringing in my ears." B) "It improves when I lie down." C) "Bright lights really bother my eyes." E) "My head hurts more when I am sitting watching tv."

Which instructions should the nurse provide to an adolescent female client who is initiating treatment with isotretinoin (Accutane) for acne vulgaris? (Select all that apply.) A) "Notify the health care provider immediately if you think you are pregnant." B) "If your acne gets worse, stop the medication and call the health care provider." C) "Take a daily multiple vitamin to prevent deficiencies and promote dermal healing." D) "Dermabrasion for deep acne scars should be postponed for 1 month after therapy is stopped." E) "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F) "Before, during, and after therapy, two effective forms of birth control must be used at the same time."

A) "Notify the health care provider immediately if you think you are pregnant." E) "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F) "Before, during, and after therapy, two effective forms of birth control must be used at the same time." - (A, E, and F) are correct. Isotretinoin (Accutane) has been found to cause pregnancy category D drug-related birth defects, premature births, and fetal death (A), which necessitates the use of effective birth control methods before, during, and after therapy (F). Accutane is associated with sadness (E), depression, suicidal ideations, and other serious mental health problems. An initial exacerbation of acne (B) is common when starting drug therapy. Accutane is a retinoid related to vitamin A, and taking additional multivitamin supplements (C) can predispose the client to vitamin A toxicity. The client should stop taking Accutane at least 6 months before cosmetic procedures, such as dermabrasion (D), because the drug can increase the chances of scarring.

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which client questions indicate a need for additional teaching in the cognitive domain? Select all that apply. A) "What is diabetes?" B) "What will my friends think?" C) "How do I give myself an injection?" D) "Can you tell me how the glucose monitor works?" E) "How do I get the insulin from the vial into the syringe?"

A) "What is diabetes?" D) "Can you tell me how the glucose monitor works?" - Option C falls in the affective domain. Option E falls into the psychomotor domain.

A client who is scheduled to have an abdominal panhysterectomy asks the nurse how the surgery will affect her periods. How should the nurse respond? A) "You will not have any more periods." B) "Your periods will become more regular." C) "Your periods will become lighter until they disappear." D) "You will notice that the time between periods will be longer."

A) "You will not have any more periods."

The nurse is administering the early morning dose of insulin aspart (NovoLog), 5 units subcutaneously, to a client with diabetes mellitus type 1. The client's fingerstick serum glucose level is 140 mg/dL. Considering the onset of insulin aspart (NovoLog), when should the nurse ensure that the client's breakfast be given? A) 5 minutes after subcutaneous administration B) 30 minutes after subcutaneous administration C) 1 to 2 hours after administration D) Any time because of a flat peak of action

A) 5 minutes after subcutaneous administration - Insulin aspart is a very rapidly acting insulin, with an onset of 5 to 15 minutes. Insulin aspart (NovoLog) should be administered when the client's tray is available (A). Insulin aspart (NovoLog) peaks in 45 minutes to 1½ hours (B and C) and has a duration of 3 to 4 hours. The client should have eaten to ensure absorption of the meal so that serum glucose levels will coincide with the peak. Insulin glargine (Lantus) has a flat peak of action (D) and is usually given at bedtime.

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A) A 6-month-old with failure to thrive that has a closed anterior fontanel. B) A 24-month-old with gastroenteritis that has a closed posterior fontanel. C) A 2-month-old with chickenpox that has an open posterior fontanel. D) A 28-month-old with hydrocephalus that has an open anterior fontanel.

A) A 6-month-old with failure to thrive that has a closed anterior fontanel. - At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D).

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A) A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B) Pneumonia, with a sputum culture of gram-negative bacteria C) Urinary tract infection, with positive blood cultures D) Culture of a diabetic foot ulcer shows gram-positive cocci

A) A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) - The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.

Which clinical indicators identified by the nurse support the probably presence of fecal impaction in a client? Select all that apply. A) Abdominal cramps B) Fecal liquid seepage C) Hyperactive bowel sounds D) Bright red blood in the stool E) Decreased number of bowel movements

A) Abdominal cramps B) Fecal liquid seepage C) Hyperactive bowel sounds

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? A) Accept the client's behavior B) Explore the situation with the client C) Withdraw from contact with the client D) Tell the client the reason for the staff's actions

A) Accept the client's behavior - At this time, the client is using this behavior as a coping mechanism, and accepting the client's behavior is the best action by the nurse.

An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac (Toradol) 30 mg IV q6h. Which action should the nurse implement? A) Administer both medications according to the prescription. B) Hold the ketorolac to prevent an antagonistic effect. C) Hold the morphine to prevent an additive drug interaction. D) Contact the healthcare provider to clarify the prescription.

A) Administer both medications according to the prescription. - Morphine and ketorolac (Toradol) can be administered concurrently (A), and may produce an additive analgesic effect, resulting in the ability to reduce the dose of morphine, as seen in this prescription. Toradol is an antiinflammatory analgesic, and does not have an antagonistic effect with morphine (B), like an agonist-antagonist medication would have. An additive analgesic effect is desirable (C), because it allows a reduced dose of morphine. This prescription does not require any clarification, and can be administered safely as written (D).

The nurse performs a client assessment prior to the administration of a prescribed dose of dipyridamole and aspirin (Aggrenox) PO. The nurse notes that the client's carotid bruit is louder than previously assessed. Which action should the nurse implement? A) Administer the prescribed dose of Aggrenox as scheduled. B) Hold the dose of Aggrenox until the health care provider is contacted. C) Advise the client to take nothing by mouth until further assessment is completed. D) Elevate the head of the bed and apply oxygen by nasal cannula.

A) Administer the prescribed dose of Aggrenox as scheduled. - A carotid bruit reflects the degree of blood vessel turbulence, which is typically the result of atherosclerosis. Aggrenox is prescribed to reduce platelet aggregation and should be administered to this client, who is at high risk for thrombus occlusion (A). (B, C, and D) are not necessary interventions at this time.

The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individual(s)? (Select all that apply.) A) An Rh-negative woman who has had a miscarriage at 24 weeks B) The father of a baby of an Rh-positive fetus C) An Rh-negative mother after delivery with an Rh-positive infant with a negative direct Coomb's test D) An Rh-positive infant within 72 hours of birth E) An Rh-negative mother with a negative antibody titer at 28 weeks

A) An Rh-negative woman who has had a miscarriage at 24 weeks C) An Rh-negative mother after delivery with an Rh-positive infant with a negative direct Coomb's test E) An Rh-negative mother with a negative antibody titer at 28 weeks - (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D)

Which nursing intervention has the highest priority during IV administration of mechlorethamine HCl (nitrogen mustard) and actinomycin (Actinomycin D)? A) Assess for extravasation at the IV site during infusion. B) Premedicate with antiemetics 30 to 60 minutes before infusion. C) Monitor cardiac rate and rhythm during the IV infusion. D) Check the granulocyte count daily for the presence of neutropenia.

A) Assess for extravasation at the IV site during infusion. - Mechlorethamine HCl (nitrogen mustard) and actinomycin (Actinomycin D) are vesicants; therefore, assessment for blister formation and/or tissue sloughing that can occur with leakage of these agents into surrounding subcutaneous tissues is essential to ensure client safety during the IV infusion (A). (B, C, and D) do not have the priority of (A) during the administration of vesicants.

Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?

A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods ****D) Note patterns of increased blood pressure

A client enters the emergency department, reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention? A) Assess vital signs B) Insert a saline lock C) Place client on oxygen D) Draw blood for troponins

A) Assess vital signs

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A) Assist the client to walk to the bathroom and do not leave the client alone. B) Request that the UAP assist the client onto a bedpan. C) Ask if the client needs to have a bowel movement or void. D) Assess the client's bladder to determine if the client needs to urinate.

A) Assist the client to walk to the bathroom and do not leave the client alone. - Barbiturates cause central nervous system (CNS) depression and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed (D).

A spouse spends most of the day with a client who is receiving chemotherapy for an inoperable cancer. The spouse says to the nurse, "What can I do to help?" How can the nurse support the client's spouse? A) Assist the couple to maintain open communication B) Offer the couple a description of the disease progression C) Instruct the spouse about the action of the mediations D) Meet privately with the spouse to explore feelings

A) Assist the couple to maintain open communication

The nurse notes a client's postoperative leg is cool with a capillary refill greater than 4 seconds and calls the healthcare provider. After 30 minutes of not receiving a return call from the healthcare provider, which action should the nurse take first? A) Attempt to recall the same healthcare provider. B) Notify the hospital's on call nursing supervisor. C) Continue to monitor and call if there is a change. D) Describe the problem to the answering service.

A) Attempt to recall the same healthcare provider. - The healthcare provider may have inadvertently not received the first call, so (A) is the best action to take first. According to the TeamSTEPPS, two attempts should be made to notify the provider before proceeding through the chain of command (B). (C) should be implemented, but these assessment findings require immediate medical action. Although (D) is an option, the client's urgent condition needs treatment.

The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A) Blood pressure of 90/56 mm Hg B) Apical pulse rate of 68 beats/min C) Potassium level of 3.3 mEq/L D) Urine output of 200 mL in 4 hours

A) Blood pressure of 90/56 mm Hg - Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D).

A 26-year-old primigravida client is experiencing increasing discomfort and anxiety during the active phase of labor. She requests something for pain. Which analgesic should the nurse anticipate administering? A) Butorphanol (Stadol) B) Hydromorphone (Dilaudid) C) Morphine sulfate D) Codeine sulfate

A) Butorphanol (Stadol) - Butorphanol (Stadol) (A) is a mixed agonist-antagonist analgesic resulting in good analgesia but with less respiratory depression, nausea, and vomiting compared with opioid agonist analgesics (B, C, and D).

A nurse is caring for a client with a history of COPD. WHat complications are most commonly associated with COPD? A) Cardiac problems B) Joint inflammation C) Kidney dysfunction D) Peripheral neuropathy

A) Cardiac problems

A nurse is teaching about excellent food sources of vitamin A for a client who is deficient in this vitamin. WHich foods should the nurse include in the teaching? Select all that apply. A) Carrots B) Oranges C) Tomatoes D) Skim milk E) Leafy greens

A) Carrots E) Leafy greens

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client? A) Check residual volume every four hours. B) Stimulate the gag reflex every eight hours. C) Administer small amounts of the formula. D) Give the feeding while the client is supine.

A) Check residual volume every four hours. - The gastric residual volume should be assessed every four hours (A) to evaluate absorption of the feeding and to determine delayed gastric emptying. (C) is not indicated unless the client cannot tolerate the prescribed volume of feeding. (B and D) are contraindicated. Stimulating the gag reflex (B) and administering NG feedings while the client is supine (D) increases the risk of aspiration.

What should the nurse do when collecting a 24-hour urine specimen? A) Check to verify if a preservative is needed B) Weigh the client before starting the collection C) Discard the last voided specimen of the 24-hour period D) Assess the client's intake and output for the previous 24-hour period

A) Check to verify if a preservative is needed

Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) A) Child's height and weight. B) Adult dosage of medication. C) Body surface area of child. D) Average adult's body surface area. E) Average pediatric dosage of medication. F) Nomogram determined mathematical constant.

A) Child's height and weight. C) Body surface area of child. F) Nomogram determined mathematical constant. - Correct selections are (A, C, and F). The most accurate calculations of pediatric dosages use the child's height and weight (A). The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131 (C), then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram (F) is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose. (B, D, and E) are not used to calculate pediatric dosages.

A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. B) Negative feelings of doubt and shame are characteristic of 4-year-old children. C) Role conflict is a common problem of children this age. She is just wondering where she fits into society. D) At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.

A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. - Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the "Autonomy vs. Shame and Doubt," stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the "Identity vs. Role Confusion" stage. (D) describes a child 6 to 12 years of age, the "Industry vs. Inferiority" stage.

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A) Confusion B) Peripheral edema C) Crackles in the lungs D) Dyspnea E) Distended neck veins

A) Confusion C) Crackles in the lungs D) Dyspnea - Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion (A, C, and D). (B and E) are associated with right-sided heart failure.

A nurse is assessing a client with a diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids. Select all that apply. A) Constipation B) Hypertension C) Eating spicy foods D) Bowel incontinence E) Numerous pregnancies

A) Constipation E) Numerous pregnancies

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A) Count the client's respirations B) Document the intensity of the client's pain C) Withhold the medication if the client reports pruritus D) Verify the number of doses in the locked cabinet before administering the prescribed dose E) Discard the medication in the client's toilet before leaving the room if the medication is refused

A) Count the client's respirations B) Document the intensity of the client's pain D) Verify the number of doses in the locked cabinet before administering the prescribed dose - Pruritus is a common side effect that can be managed with antihistamines. The nurse should NOT discard the opioid in the patient's room. Any waste of an opioid must be witnessed by another nurse.

While preparing a client for her first Pap smear, a nurse determines that she appears anxious. What should the nurse include as part of the teaching plan? A) Current statistics on the incidence of cervical cancer B) Description of the early symptoms of cervical cancer C) Explanation of why there is a small risk for cervical cancer D) Written instructions about the purpose of a pap smear

A) Current statistics on the incidence of cervical cancer

A client had a suprapubic prostatectomy. Which type of tube can the nurse expect the client to have when he returns to his room from the PACU? A) Cystostomy B) NG C) Nephrostomy D) Ureterostomy

A) Cystostomy

Which intervention is most important for a nurse to implement prior to administering atropine PO? A) Determine the presence of 5 to 35 bowel sounds/min. B) Assess the blood pressure, both lying and standing. C) Verify that the client's tendon reflexes are 2+. D) Have the client rate his or her pain on a 0 to 10 scale.

A) Determine the presence of 5 to 35 bowel sounds/min. - Anticholinergic drugs, such as atropine, have antispasmodic and antisecretory properties, which relax the gastrointestinal tract, and are therefore contraindicated in a client with intestinal atony (A). Anticholinergic drugs do not have an effect on (B) (used to determine dehydration) or (C). Atropine itself has no analgesic effect; it is used with opioids to potentiate their effect (D).

A client has an anterior and posterior surgical repair of a cystocele and rectocele and returns from the PACU with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? A) Discomfort is minimized B) Bladder tone is maintained C) Urinary retention is prevented D) Pressure on the suture line is relieved E) Hourly urine output can be easily measured

A) Discomfort is minimized C) Urinary retention is prevented D) Pressure on the suture line is relieved

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A) Document that the client responds to painful stimulus. B) Observe the client's response to verbal stimulation. C) Place the client on seizure precautions for 24 hours. D) Report decorticate posturing to the health care provider.

A) Document that the client responds to painful stimulus. - The client has demonstrated a purposeful response to pain, which should be documented as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not before (B). There is no indication for placing the client on seizure precautions (C). Reporting (D) is nonpurposeful movement.

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply. A) Wrinkled, thin skin B) Multiple sole creases C) Small breast bud size D) Presence of scrotal rugae E) Pinna remaining flat when folded

A) Wrinkled, thin skin C) Small breast bud size E) Pinna remaining flat when folded

A chemotherapeutic regimen with doxorubicin HCl (Adriamycin) is being planned for a client recently diagnosed with cancer. What diagnostic test results should the nurse review prior to initiating this treatment? A) Electrocardiogram (ECG) B) Arterial blood gases (ABGs) C) Serum cholesterol level D) Pelvic ultrasound

A) Electrocardiogram (ECG) - Baseline cardiac function studies (A) are required to monitor the irreversible cardiotoxic effects of doxorubicin HCl (Adriamycin). (B) assesses disturbances of acid-base balance. (C) is not affected by this chemotherapeutic agent. (D) is used to detect pelvic abnormalities such as tumors but is not specific for the administration of Adriamycin.

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A) Encourage staff to participate in online in-service education. B) Assign staff to make sure that all equipment is thoroughly cleaned. C) Ask which staff members would like to go home for the remainder of the day. D) Notify the supervisor that the staff needs additional assignments.

A) Encourage staff to participate in online in-service education. - Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census (A). (B) is not the responsibility of the nursing staff. (C) is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary (D).

A nurse is working with a client who has the diagnosis of borderline personality disorder with antisocial behavior. What personality traits should the nurse expect the client to exhibit. Select all that apply. A) Engaging B) Indecisive C) Withdrawn D) Manipulative E) Perfectionist

A) Engaging D) Manipulative

What nursing actions best promote communication when obtaining a nursing history? Select all that apply. A) Establishing eye contact B) Paraphrasing the client's message C) Asking "why" and "how" questions D) Using broad, open-ended statements E) Reassuring the client that there is no cause for alarm F) Asking questions that can be answered with a "yes" or "no"

A) Establishing eye contact B) Paraphrasing the client's message D) Using broad, open-ended statements

A client who has just had a kidney transplant is transferred from the PACU to the ICU. How often should the nurse in the ICU monitor the client's urinary output? A) Every hour B) Every 2 hours C) Every half hour D) Every 15 minutes

A) Every hour

356. A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first?

Administer a prescribed bronchodilator.

A client with hyperlipidemia receives a prescription for niacin (Niaspan). Which client teaching is most important for the nurse to provide? A) Expected duration of flushing. B) Symptoms of hyperglycemia. C) Diets that minimize GI irritation. D) Comfort measures for pruritis.

A) Expected duration of flushing - Flushing of the face and neck, lasting up to an hour, is a frequent reason for discontinuing niacin. Inclusion of this effect in client teaching (A) may promote compliance in taking the medication. While (B, C, and D) are all worthwhile instructions to help clients minimize or cope with normal side effects associated with niacin (Niaspan), flushing is intense and causes the most concern for the client.

A nurse is caring for a client who is 2 days postoperative following a lumber laminectomy and is reporting nausea. Which of the following actions should the nurse take first?

Administer an antiemetic

A nurse is caring for an underweight adolescent girl who is diagnosed with anorexia nervosa. WHat are common characteristics of girls with this disorder that the nurse should identify when obtaining a health history and performing a physical assessment. Select all that apply. A) Fatigue B) Pyrexia C) Tachycardia D) Heat intolerance E) Secondary amenorrhea

A) Fatigue E) Secondary amenorrhea

A client who is hypertensive receives a prescription for hydrochlorothiazide (HCTZ). When teaching about the side effects of this drug, which symptoms are most important for the nurse to instruct the client to report? A) Fatigue and muscle weakness B) Anxiety and heart palpitations C) Abdominal cramping and diarrhea D) Confusion and personality changesA

A) Fatigue and muscle weakness - Thiazide diuretics, such as HCTZ, cause potassium wasting in the urine, so the client should be instructed to report fatigue and muscle weakness (A), which are characteristic of hypokalemia. Although (B, C, and D) should be reported, they are not indicative of hypokalemia, which is a side effect of HCTZ that can cause cardiac dysrhythmias.

To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.) A) Fish. B) Beef. C) Vitamin C tablets. D) Turkey. E) Ibuprofen (Advil). F) Coffee.

A) Fish. B) Beef. C) Vitamin C tablets. E) Ibuprofen (Advil). - Correct selections are (A, B, C, and E). The fecal occult blood test, or guaiac test, measures microscopic amounts of blood in the feces. False positive results can occur from food products such as fish (A), beef and other red meats (B), green vegetables, vitamin C supplements (C), aspirin, and nonsteroidal antiinflammatory medications, including ibuprofen (E). (D and F) do not affect the results of fecal occult blood testing.

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her HCP. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A) Give the infant to the client and instruct her regarding the infant's care B) Explain to the client that she can leave, but her infant must remain in the hospital C) Emphasize to the client that the infant is a minor and legally must remain until orders are received D) Tell the client that hospital policy prevents the staff from releasing the infant until ready to discharge

A) Give the infant to the client and instruct her regarding the infant's care - When a client signs herself and her infant out of the hospital, she is legally responsible for her infant.

When a developmental appraisal is performed on a 6-month-old infant, which observation is most important to the nurse in light of a diagnosis of hydrocephalus? A) Head lag B) Positive Babinski reflex C) Inability to sit unsupported D) Absence of the grasp reflex

A) Head lag

The health care provider prescribes oral contraceptives for a client who wants to prevent pregnancy. Which information is the most important for the nurse to provide to this client? A) Take one pill at the same time every day until all the pills are gone. B) Use condoms and foam instead of the pill while on any antibiotics. C) Limit sexual intercourse for at least one cycle after starting the pill. D) Use another contraceptive if two or more pills are missed in one cycle

A) Take one pill at the same time every day until all the pills are gone. - To maintain adequate hormonal levels for contraception and enhance compliance, oral contraceptives should be taken at the same time each day (A). There is no strong pharmacokinetic evidence that shows a relationship between the category of broad-spectrum antibiotic use and altered hormone levels in oral contraceptive users, so (B) is not indicated at this time. Abstinence (C) is the best method to prevent pregnancy during the first cycle. If a client misses two pills during the first week (D), the client should take two pills a day for 2 days and finish the package while using a backup method of birth control until her next menstrual cycle.

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? A) Tell the student to proceed directly to his regularly scheduled class. B) Call the parent and suggest re-taking the student's temperature at home. C) Give the student a glass of cool fluids, then retake his temperature. D) Send the student to class, but re-verify his temperature after lunch.

A) Tell the student to proceed directly to his regularly scheduled class. - This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100° F is normal for this student at this time. The student should attend class (A) since no further nursing action is required. (B) would alarm the parents unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since these findings are within normal limits.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? A) Hepatitis C B) Influenza type B C) MMR D) DTaP

A) Hepatitis C

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A) Hourly urine output B) Bladder distention C) Urinary incontinence D) Intraoperative bladder decompression E) Urine sample for culture

A) Hourly urine output B) Bladder distention D) Intraoperative bladder decompression - Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

When planning care for a client with polycystic kidney disease, which collaborative problem has the highest priority? A) Hypertension. B) Calculi formation. C) Acute renal failure. D) Infection.

A) Hypertension. - Blood pressure control (A) has the highest priority, which is necessary to reduce cardiovascular complications and slow the progression of renal dysfunction, which can contribute to (B, C, and D).

473. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Contact the regional organ procurement agency

What should the nurse consider when obtaining informed consent from a 17-year-old adolescent? A) If the client is allowed to give consent B) The client cannot make informed decisions about health care C) If the client is permitted to give voluntary consent when parents are not available D) The client probably will be unable to choose between alternatives when asked to consent

A) If the client is allowed to give consent - A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent.

A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned on the shower in full force. What term best describes this experience? A) Illusion B) Delusion C) Dissociation D) Hallucination

A) Illusion - An illusion is a misperception of an actual stimulus

Three days after birth, a breastfeeding newborn becomes jaundice. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin level. The test result is 12 mg/DL. The nurse explains that it is physiologic jaundice, a benign condition which is caused by: A) Immature liver function B) An inability to synthesize bile C) An increased maternal hemoglobin level D) High hemoglobin with low hematocrit levels

A) Immature liver function

A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. WHat should the nurse conclude is the reason why metabolic acidosis develops with kidney failure? A) Inability of the renal tubules to secrete hydrogen ions to conserve bicarbonate B) Depressed RR by metabolic wastes, causing CO2 retention C) Inability of the renal tubules to reabsorb water to dilute the acid contents of blood D) Impaired glomerular filtration, causing retention of sodium and metabolic waste products

A) Inability of the renal tubules to secrete hydrogen ions to conserve bicarbonate

Which instruction(s) should the nurse give to a female client who just received a prescription for oral metronidazole (Flagyl) for treatment of trichomonas vaginalis? (Select all that apply.) A) Increase fluid intake, especially cranberry juice. B) Do not abruptly discontinue the medication; taper use. C) Check blood pressure daily to detect hypertension. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time.

A) Increase fluid intake, especially cranberry juice. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time. - Correct selections are (A, D, E, and F). Increased fluid intake and cranberry juice (A) are recommended for prevention and treatment of urinary tract infections, which frequently accompany vaginal infections. It is not necessary to taper use of this drug (B) or to check the blood pressure daily (C), as this condition is not related to hypertension. Flagyl can cause a disulfiram-like reaction if taken in conjunction with ingestion of alcohol, so the client should be instructed to avoid alcohol (D). All sexual partners should be treated at the same time (E) and condoms should be used until after treatment is completed to avoid reinfection (F).

The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A) Increase in T3 and T4 B) Decrease in heart rate C) Increase in TSH D) Decrease in urine output E) Decrease in periorbital edema

A) Increase in T3 and T4 E) Decrease in periorbital edema - Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine (Synthroid) (B and C). Levothyroxine does not affect urine output (D).

The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?

A) Increased serum glucose B) Decreased albumin ***C) Decreased potassium D) Increased sodium retention

A nurse applies an ice pack to a client's leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment? A) Local anesthesia B) Peripheral vasodilation C) Depression of VS D) Decreased viscosity of blood

A) Local anesthesia

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin (Pitocin) infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A) Maternal temperature B) Fetal blood pressure C) Maternal respiratory rate D) Fetal heart rate E) Maternal temperature

A) Maternal temperature - (A) should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. (B) cannot be established with standard bedside monitoring. (C) is not specifically related to ROM. (D) is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.

A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The HCP determines that the client is severely anemia and admits the client to the hospital. What clinical indicators does the nurse expect to identify when performing an assessment? Select all that apply. A) Melena B) Tachycardia C) Constipation D) Clay-colored stools E) Painful BM

A) Melena B) Tachycardia

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply. A) Mental confusion B) Increased cholesterol C) Brown-colored stools D) Flapping hand tremors E) Hyperactive DTRS

A) Mental confusion D) Flapping hand tremors

Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight

B

What is the priority nursing intervention on admission of a primigravida in labor? A) Monitoring the fetal heart rate B) Asking the client when she last ate C) Obtaining the client's health history D) Determining if membranes have ruptured

A) Monitoring the fetal heart rate - Monitoring the fetus for signs of distress typically takes priority.

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement? A) Notify the healthcare provider. B) Irrigate the nasogastric tube per prescription. C) Assess the client's use of the PCA device. D) Splint the abdomen to relieve pressure on the incision.

A) Notify the healthcare provider. - Although nasogastric aspirate can be bright red initially, the color should gradually darken over the first 24 hours. A sudden increase in the volume of bright red gastric drainage indicates bleeding, and the healthcare provider should be notified immediately (A). (B, C, and D) should be implemented, but the client's complaints of pain and signs of bleeding require immediate action to prevent hemorrhagic shock.

A nurse is assessing a client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? Select all that apply. A) Obesity B) Mullparity C) Cigarette smoking D) Early onset of menopause E) Family history of endometrial cancer F) Previous hormonal replacement therapy

A) Obesity E) Family history of endometrial cancer F) Previous hormonal replacement therapy

Contraceptives that have estrogen-like and/or progesterone like compounds are prepared in a variety of forms. Which contraceptives should the nurse identify as having a hormonal component? Select all that apply. A) Oral contraceptives B) Diaphragms C) Cervical caps D) Female condoms E) Foam spermicides F) Transdermal agents

A) Oral contraceptives E) Foam spermicides F) Transdermal agents

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A) Oral hygiene should be performed before the medication. B) Antifungal medications are available in tablet, suppository, and liquid forms. C) Candida albicans is the organism that causes the white lesions in the mouth. D) The dietary intake of dairy and spicy foods should be limited.

A) Oral hygiene should be performed before the medication. - HIV infection causes depression of cell-mediated immunity that allows an overgrowth of Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Mycostatin (A). (B and C) provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but (A) allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated (D).

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? A) Orient the client to the unit environment B) Have a copy of hospital regulations available C) Explain that there is no reason to be concerned D) Reassure the client that the staff is available to answer questions

A) Orient the client to the unit environment

A nurse is caring for a client who had insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client? A) Pain B) Nausea C) Excoriation D) Restlessness

A) Pain

A nurse is caring for a client who is admitted with urethral colic and hematuria. The client also has stage 1 HTN and is overweight. The decrease in which clinical indicator associated with this client's status should the nurse be most concerned about at this time? A) Pain B) Weight C) Hematuria D) HTN

A) Pain

When a disaster occurs, the nurse may have to treat mass hysteria first. Which response indicates that an individual should be cared for first? A) Panic B) Coma C) Euphoria D) Depression

A) Panic

A child with cystic fibrosis is receiving ticarcillin disodium (Ticar) for Pseudomonas pneumonia. For which adverse effect should the nurse assess and report promptly to the health care provider? A) Petechiae B) Tinnitus C) Oliguria D) Hypertension

A) Petechiae - Adverse effects of ticarcillin disodium (Ticar) include hypothrombinemia and decreased platelet adhesion, which can result in the presence of petechiae (A). (B, C, and D) are not adverse effects primarily associated with the administration of Ticar.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A) Place the client in a side-lying position. B) Pull the auricle upward and outward. C) Hold the dropper 6 cm above the ear canal. D) Place a cotton ball into the inner canal. E) Pull the auricle down and back.

A) Place the client in a side-lying position. B) Pull the auricle upward and outward. - The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A) Pulse characteristics B) Open airway C) Entrance and exit wounds D) Cervical spine injury

A) Pulse characteristics - Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity (A) is a priority. Because the client is talking, he has an open airway (B), so that assessment is not necessary. Assessing for (C and D) should occur after assessing for adequate circulation.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A) Record the amount on the client's fluid output record. B) Encourage the client to increase oral fluid intake. C) Notify the health care provider of the findings. D) Palpate the client's bladder for distention.

A) Record the amount on the client's fluid output record. - The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output (A), but no additional action is needed (B, C, and D).

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply. A) Refrain from smoking around the infant. B) Refrain from co-sleeping or bed-sharing. C) Position the infant on the side while sleeping. D) Use soft pillows to support the infant while sleeping. E) Refrain from placing stuffed toys on the infant's bed.

A) Refrain from smoking around the infant. B) Refrain from co-sleeping or bed-sharing. E) Refrain from placing stuffed toys on the infant's bed. - The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.

A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply. A) Respiratory depression B) Distension of the bladder C) Decreased blood pressure D) Fine tremor of the fingers E) High-pitched gurgling bowel sounds

A) Respiratory depression C) Decreased blood pressure E) High-pitched gurgling bowel sounds

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

A) Reverse B) Airborne C) Standard precautions ***D) Contact Ans: D

The nurse witnesses a male client's signature for surgical consent for a Billroth II procedure after the surgeon discusses the procedure and its implication with the client. After signing the consent, the client questions the importance of a change in his diet postoperatively. What action should the nurse implement? A) Review information about dumping syndrome. B) Have the client sign another consent. C) Notify the surgeon about the client's comment. D) Explain the surgical procedure.

A) Review information about dumping syndrome. - Further review of information about potential dumping syndrome (A), which is managed postoperatively with dietary modification after a Billroth II procedure (partial gastrectomy), should be explained to address the client's expressed concern. (B) is not necessary since informed consent verifies the client's understanding of surgical risks and the surgical procedure. (C) is not indicated because the client does not question his consent for the surgery. (D) may be indicated if the client asks for further interpretation of the surgeons's explanation.

Which client is most likely to be at risk for spiritual distress? A) Roman Catholic woman considering an abortion B) Jewish man considering hospice care for his wife C) Seventh-Day Adventist who needs a blood transfusion D) Muslim man who needs a total knee replacement

A) Roman Catholic woman considering an abortion - In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A) Save the next urine sample. B) Restrict oral fluid intake. C) Strain all voided urine. D) Reduce physical activity.

A) Save the next urine sample. - The nurse should instruct the client to save the next urine sample (A) for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.

A nurse is teaching sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. What does the family member do during a return demonstration that indicates further teaching is necessary? A) Sets the sterile field on the client's linens at the front of the bed B) Touches the outer inch of the sterile field when placing it on a flat surface C) Checks expiration dates on the sterile packages before donning sterile gloves D) Picks up wet gauze with sterile plastic forceps, holding the tips lower than the wrist

A) Sets the sterile field on the client's linens at the front of the bed

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A) Shave the area where the TENS will be placed. B) Obtain small needles for insertion. C) Place the TENS unit directly over or near the site of pain. D) Explain to the client that drowsiness may occur immediately after using TENS. E) Describe the use of TENS for postoperative procedures such as dressing changes.

A) Shave the area where the TENS will be placed. C) Place the TENS unit directly over or near the site of pain. E) Describe the use of TENS for postoperative procedures such as dressing changes. - The correct choices are (A, C, and E). The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

A nurse is teaching clients to determine the time of ovulation by taking the basal temperature. What change is expected to occur in the basal temperature during ovulation? A) Slight drop and then rises B) Sudden rise and then drops C) Marked rise and remains high D) Marked drop and remains lower

A) Slight drop and then rises

A homeless person is brought into the ED after prolonged exposure to cold weather. WHat clinical manifestations of hypothermia does the nurse anticipate? Select all that apply. A) Stupor B) Erythema C) Increased anxiety D) Rapid respirations E) Paresthesia in the affected body parts

A) Stupor E) Paresthesia in the affected body parts

During the initial nursing assessment history, a client tells the nurse that he is taking tetracycline hydrochloride (Sumycin) for urethritis. Which medication taken concurrently with Sumycin could interfere with its absorption? A) Sucralfate (Carafate) B) Hydrochlorothiazide (Diuril) C) Acetaminophen (Tylenol) D) Phenytoin (Dilantin)

A) Sucralfate (Carafate) - Sucralfate (Carafate) (A) is used to treat duodenal ulcers and will bind with tetracycline hydrochloride (Sumycin), inhibiting this antibiotic's absorption. (B, C, and D) have no drug interaction properties that prohibit concurrent use with tetracycline hydrochloride (Sumycin).

163. Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Aural migraine headaches.

Methenamine mandelate (Mandelamine) is prescribed for a client with a urinary tract infection and renal calculi. Which finding indicates to the nurse that the medication is effective? A) The frequency of urinary tract infections decreases. B) The urine changes color and pain is diminished. C) The dipstick test changes from +1 to trace. D) The daily urinary output increases by 10%.

A) The frequency of urinary tract infections decreases. - Mandelamine is prescribed to acidify the urine, decreasing the incidence of calcium phosphate calculi and urinary tract infections (A). (B) is related to the administration of pyridine (Pyridium). Mandelamine has no effect on (C or D).

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while this monitor is in place? A) The most comfortable position can be assumed B) Monitoring is more accurate in the side-lying position C) The monitor leads can be detached when sitting on the bedpan D) Maintaining a supine position holds the internal electrodes in place

A) The most comfortable position can be assumed

A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. Why must the nurse notify the HCP to remove it immediately? A) The radioactive packing will injure healthy tissue B) Removal of the packing will prevent excessive blood loss C) The exposure of radium to the environment will diminish its effectiveness D ) Removal of the packing will minimize life-threatening contact with the radiation

A) The radioactive packing will injure healthy tissue

A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent? A) Trying to rest B) Playing sports C) Watching television D) Interacting with others

A) Trying to rest

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A) Use a happy-face/sad-face pain scale. B) Ask the mother if she thinks the analgesic is working. C) Assess for changes in the child's vital signs. D) Teach the child to point to a numeric pain scale.

A) Use a happy-face/sad-face pain scale. - A 4-year-old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear. (D) requires abstract number skills beyond the level of a 4-year-old.

A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? A) Use a pillow to keep the legs abducted B) Elevate the client's affected limb on a pillow C) Turn the client using the log-rolling technique D) Place a trochanter roll along the entire extremity

A) Use a pillow to keep the legs abducted

A category X drug is prescribed for a young adult female client. Which instruction is most important for the nurse to teach this client? A) Use a reliable form of birth control. B) Avoid exposure to ultra violet light. C) Refuse this medication if planning pregnancy. D) Abstain from intercourse while on this drug.

A) Use a reliable form of birth control. - Drugs classified in the category X place a client who is in the first trimester of pregnancy at risk for teratogenesis, so women in the childbearing years should be counseled to use a reliable form of birth control (A) during drug therapy. (B) is not a specific precaution with Category X drugs. The client should be encouraged to discuss plans for pregnancy with the healthcare provider, so a safer alternative prescription (C) can be provided if pregnancy occurs

A newborn with acquired herpes simplex virus infection is being discharged. Which developmental pattern is important for the nurse to teach the parents to monitor? A) Visual clarity B) Renal function C) Long bone growth D) Responses to sounds

A) Visual clarity - Ocular disease is common in patients with herpes simplex virus infections.

How should the nurse prepare an IV piggyback medication for administration to a client receiving an IV infusion? Select all that apply. A) Wear clean gloves to check the IV site B) Rotate the bag after adding the medication C) Use 100 mL of fluid to mix the medication D) Change the needle before adding the medication E) Place the IVPB at a lower level than the existing IV F) Use sterile technique when preparing the medication

A) Wear clean gloves to check the IV site B) Rotate the bag after adding the medication F) Use sterile technique when preparing the medication

The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? A) Withhold the scheduled dose. B) Check the client's apical pulse. C) Notify the healthcare provider. D) Repeat the serum potassium level.

A) Withhold the scheduled dose. - The nurse should first withhold the scheduled dose of Cozaar (A) because the client is hyperkalemic (normal range 3.5 to 5 mEq/L). Although hypokalemia is usually associated with diuretic therapy in heart failure, hyperkalemia is associated with several heart failure medications, including ARBs. Because hyperkalemia may lead to cardiac dysrhythmias, the nurse should check the apical pulse for rate and rhythm (B), and the blood pressure. Before repeating the serum study (D), the nurse should notify the healthcare provider (C) of the findings.

489. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Contact the regional organ procurement agency

When assessing a normal newborn, which finding(s) should the nurse expect? (Select all that apply.) A.Umbilical cord contains one vein and two arteries B.Slightly edematous labia in the female newborn C.Absence of Babinski reflex D.Presence of white plaques on the cheeks and tongue E.Nasal flaring noted with respirations

A,B Rationale: These are normal findings (A and B). The others indicate abnormalities or complications and should be reported to the primary health care provider (C, D, and E).

The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) A.Dark red vaginal bleeding B.Rigid boardlike abdomen C.Soft abdomen on palpation D.Complaints of severe abdominal pain E.Painless bright red vaginal bleeding

A,B,D Rationale: These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E).

The nurse teaches a class on bioterrorism. Which method(s) of transmission is(are) possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A.Inhalation of powder form B.Handling of infected animals C.Spread from person to person through coughing D.Eating undercooked meat from infected animals E.Direct cutaneous contact with the powder

A,B,D,E Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply. A) Mental confusion B) Increased cholesterol C) Brown-colored stools D) Flapping hand tremors E) Hyperactive DTRS

A,D

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A.Shave the area where the TENS will be placed. B.Obtain small needles for insertion. C.Place the TENS unit directly over or near the site of pain. D.Explain to the client that drowsiness may occur immediately after using TENS. E.Describe the use of TENS for postoperative procedures such as dressing changes.

ACE The correct choices are (A, C, and E). The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) A.Report lithium level of 2.0 mEq/L to the primary health care provider. B.Encourage competitive physical activities as part of the client's therapy. C.Provide an environment with increased stimuli to engage the client. D.Maintain consistent salt levels in the diet when client is taking lithium. E.Assess the client's nutritional and hydration status.

ADE A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli is therapeutic for the manic phase (C).

67. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

34. A client with bacterial meningitis is receiving phenytoin (Dilantin) Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin? a) Decrease in intracranial pressure and cerebral edema b) Increased time of ambulation between periods of rest c) Normal electroencephalogram after drug administration d) Absence of seizure activity for the duration of treatment

Absence of seizure activity for the duration of treatment

A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?

Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver (A) function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as n onsteroidal anti-inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place the client at risk for toxic reactions related to (C or D).

The nurse is planning care for a client who is having abdominal surgery. To achieve desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?

Administer analgesics prior to encouraging progressive activities and ambulation.

A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse?

Administer isoniazid (INH) daily for 6 to 9 months.

75. A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

139. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?

Administer the analgesic as requested

Which hematologic symptoms might be noted in a patient with cirrhosis of the liver? SATA

Anemia Leukopenia Thrombocytopenia

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

Allopurinol (Zyloprim)

532. The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take?

Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.

A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide?

Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended. (D) is not indicated.

The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?

An African-American client may have slightly yellow sclerae.

465. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?

Ask the family to identify a specific spokesperson

295. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take?

Ask the new person to move belonging to accommodate others

554. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?

Determine the infant's blood sugar level

578. A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend?

Drink chamomile tea at breakfast and in the evening.

495. The healthcare provider prescribes heparin protocol at18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.)

Answer 12

150. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer 83

A client has a suspected peptic ulcer in the duodenum. What should the nurse expect the client to report when describing the pain associated with this disease?

Answer : A gnawing sensation relieved by food.The act of eating allows the hydrochloric acid in the stomach to work on and be neutralized by food rather than irritate the intestinal mucosa.

382. A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)

Answer: 1.6

141. The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.

Answer: 12160

556. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?

Enable clients to become active participants in controlling the disease process

210. The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?

Antibiotics

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?

Antibiotics

Phenytoin for seizures\meningitis

Anticonvulsant It can treat and prevent seizures.

Divaloproex Sodium (Depakote)

Antiepileptic

112. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

Anxiety

185. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Anxiety related to fear of suffocation.

506. The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply)

Apple juice Chicken broth.

A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?

Apply a water soluble lubricant to the lips, oral mucosa and nares. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance.

606. A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo

respiratory alkalosis

Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.

49. When should intimate partner violence (IPV) screening occur? a) Once the clinician confirms a history of abuse b) Only when a client [resents with an unexplained injury c) As soon as the clinician suspects a problem d) As a routine part of each health care encounter

As a routine part of each health care encounter

336. When should intimate partner violence (IPV) screening occur?

As a routine part of each healthcare encounter

Antibiotic effectiveness

Ask client about allergies to medications. Ask client to state name Ask client to state DOB

154. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Ask the older brother how he felt during the incident.

The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?

Ask the spouse to step out for a few minutes.

325. An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement?

Assign staff to monitor what the client eats.

443. The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?

Assist cardiac nurses with their assignments

42. A 3 year old boy is brought to the emergency room after the mother found the child in the back yard holding a piece of toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? a. Request a stat chest x ray and prepare medications for an asthmatic episode. b. Obtain a pulse oximetry reading an arterial blood gases. c. Determine if the child ingested a toxic substance and if vomiting occurred d. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver

Auscultate all pulmonary lung fields and attempt a Heimlich maneuver

450. A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement?

Auscultate all quadrant of the abdomen.

384. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Auscultate for irregular heart rate.

28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

Auscultate the client's bowel sounds

433. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?

Auscultated bilateral breath sounds

82. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a) Review the heart rhythm on cardiac monitors b) Check urinary catheter for obstruction c) Auscultated bilateral breath sounds d) Give PRN dose of lorazepam (Ativan)

Auscultated bilateral breath sounds

305. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?

Avoid crowds for first two months after surgery.

104. The nurse should teach the client to observe which precaution while taking dronedarone?

Avoid grapefruits and its juice

The home care nurse provides self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply

Avoid prolonged standing or sitting Use recliner for long period of sitting continue wearing elastic stocking

424. The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply

Avoid prolonged standing or sitting Use recliner for long period of sitting continue wearing elastic stocking

Which information should the nurse give a client with chronic kidney disease (CKD)?

Avoid salt substitutes. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD.

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?

Avoid sharing towels and washcloths with siblings.

140. The nurse is preparing an older client for discharge following cataract extractions. Which instructions should be included in the discharge teaching? a. Limit exposure to sunlight during the first 2 weeks when the cornea is healing b. Do not read without direct lighting for 6 week. c. Avoid straining at stool, bending or lifting heavy objects d. Irrigate conjunctiva with ophthalmic saline prior to initiating antibiotic ointment

Avoid straining at stool, bending or lifting heavy objects

309. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?

Avoid straining at stool, bending, or lifting heavy objects.

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply? A) "What makes you think you have cancer?" B) "I don't know if you do; let's talk about it." C) "Why don't you discuss this with your healthcare provider?" D) "You needn't worry now; we won't know the answer for a few days."

B) "I don't know if you do; let's talk about it."

After a teaching session, the nurse evaluates the client's understanding of hypoparathyroidism. Which statement made by the client indicates the need for further education? A) "I should eat an orange a day." B) "I should include yogurt in my diet." C) "I should perform mild exercises daily." D) "I should sit outside in the sun."

B) "I should include yogurt in my diet." - Further education is needed for the client. Clients with hypoparathyroidism have hypocalcemia. In order to replenish the calcium levels of the body, the client should consume foods that are rich in calcium. However, foods rich in phosphorus such as yogurt, processed cheese, and milk should be avoided. All the other comments are correct and require no further education by the nurse. Oranges are good source of vitamin C and fibers. They help to improve healing and remove wastes from the body. Exercising is good for overall health. Sitting in the sun allows exposure of the client to sunlight, which is a natural source of vitamin D. Vitamin D helps in the absorption of calcium from the gastrointestinal tract.

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? A) "I should encourage fluid intake." B) "I should provide conditional positive support." C) "I should promote social interaction based on abilities." D) "I should provide ongoing assistance to family caregiver."

B) "I should provide conditional positive support." - When caring for cognitively impaired older adult, the nurse should provide unconditional positive support and respect. The nurse should encourage the client to drink fluids. The nurse should promote social interactions based on abilities. The nurse should provide ongoing assistance to family caregivers, educate them in nursing care techniques, and inform them about community resources.

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 tonight?" What is the nurse's best response? A) "I will give one capsule tonight before bedtime." B) "I will get a prescription so that the medication can be taken." C) "Does your HCP know about your child's allergy?" D) "Did you ask your HCP if your child should have this tonight?"

B) "I will get a prescription so that the medication can be taken." - Legally, a nurse cannot administer medications without a prescription from a legally licensed individual.

Parents are considering a bone marrow transplant for the child who has recurrent leukemia. THe parents ask the nurse for clarification about the procedure. What is the best response by the nurse? A) "It is rarely performed in children." B) "The immune system must be destroyed before a transplant can take place." C) "The hematopoietic stem cells are surgically implanted in the bone marrow." D) "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."

B) "The immune system must be destroyed before a transplant can take place."

A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? A) "Don't worry; these tests are routine." B) "They are done to identify other health risks." C) "They determine whether surgery will be safe." D) "I don't know; your health care provider ordered them."

B) "They are done to identify other health risks."

During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond? A) "You may use oral contraceptives because they are almost completely effective in preventing pregnancy." B) "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illness." C) "You will find that the intrauterine device is best for you because it prevents a fertilized ovum from implanting in the uterus." D) "You do not need to worry about becoming pregnant in the near future because women with your illness usually become infertile."

B) "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illness."

The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 AM, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A) 9:30 Am B) 10:30 am C) 12:00 pm D) 3:00 pm

B) 10:30 am - Regular insulin is short-acting and peaks between 2 and 3 hours after administration (B). The client is most at risk for a hypoglycemic reaction during the peak times. (A, C, and D) are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A) 14 B) 16 C) 17 D) 28

B) 16 - The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled (B). (A, C, and D) are inaccurate recordings.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A) Only an RN should be assigned to monitor this child's temperature. B) A tympanic measurement of temperature will provide the most accurate reading. C) The licensed practical nurse should be instructed to obtain rectal temperatures on this child. D) The healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.

B) A tympanic measurement of temperature will provide the most accurate reading. - (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary.

When assessing an adolescent who recently overdosed on acetaminophen (Tylenol), it is most important for the nurse to assess for pain in which area of the body? A) Flank. B) Abdomen. C) Chest. D) Head.

B) Abdomen. - Acetaminophen toxicity can result in liver damage; therefore, it is especially important for the nurse to assess for pain in the right upper quadrant of the abdomen (B), which might indicate liver damage. (A, C, and D) are not areas where pain would be anticipated.

A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. A) Provide a low-fat diet B) Administer analgesics C) Teach relaxation exercises D) Encourage walking in the hall E) Monitor cardiac rate and rhythm F) Observe for signs of hypercalcemia

B) Administer analgesics C) Teach relaxation exercises E) Monitor cardiac rate and rhythm

Which nursing interventions require the use of standard precautions? A) Giving a back rub B) Administering the first bath to a newborn C) Emptying a portable wound drainage system D) Interviewing a client in the ED E) Obtaining the BP of a client who is HIV positive

B) Administering the first bath to a newborn C) Emptying a portable wound drainage system

A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures? A) Ask the spouse to make decisions regarding life-saving measures. B) Allow the client to die with dignity and without life-prolonging techniques. C) Administer medications to ensure a painless death and end the client's suffering. D) Implement all measures of technical assistance and equipment to prolong life.

B) Allow the client to die with dignity and without life-prolonging techniques. - A living will is an advance directive that is prepared when an individual is competent to make decisions about end-of-life care that specifies withholding resuscitative measures that prolong life (B). The spouse can make decisions regarding the client's care (A) if there is a legal power-of-attorney document, not a living will. (C) is not a function of a living will. An individual should be provided life-support (D) unless a living will is available to define a client's wishes to withhold treatment that prolongs life.

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report. Select all that apply. A) Flatulence B) Anal itching C) Blood in stool D) Rectal pressure E) Pain when defecating

B) Anal itching C) Blood in stool D) Rectal pressure E) Pain when defecating

Which class of antineoplastic chemotherapy agents resembles the essential elements required for DNA and RNA synthesis and inhibits enzymes necessary for cellular function and replication? A) Alkylating agents B) Antimetabolites C) Antitumor antibiotics D) Plant alkaloids

B) Antimetabolites - Antimetabolites (B) exert their action by inhibiting the enzymes necessary for cellular function and replication. (A, C, and D) have a different mechanism of action.

The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A) Have you lost any weight in the last month? B) Are you experiencing any type of nervousness? C) When was the last time you took your synthroid? D) Are you having any problems with your vision?

B) Are you experiencing any type of nervousness? - Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).

A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress? A) Protracted descent. B) Arrest of active phase. C) Prolonged latent phase. D) Protracted active phase.

B) Arrest of active phase. - Arrest of active phase (B) is indicated if there is no change in the dilation of the cervix for 2 hours or more in a primigravida. Prolonged latent phase (C) is labor lasting longer than 20 hours in a primigravida. Protracted active phase (D) occurs when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent (A) occurs when the fetus decends less than 1 cm/hour into the pelvis.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? A) Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B) Assess the client for pain and administer pain medication as prescribed. C) Encourage the client to take short shallow breaths for 5 minutes. D) Prepare to administer sodium bicarbonate IV over 30 minutes.

B) Assess the client for pain and administer pain medication as prescribed. - These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A) 3+ protein in the urine B) Blood urea nitrogen >25 mg/dL C) Blood pH >7.45 D) Urine output, 2500 mL/day

B) Blood urea nitrogen >25 mg/dL - Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.

A nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective? A) Apples B) Broccoli C) Cherries D) Cauliflower

B) Broccoli - Thiazide diuretics get rid of potassium, so the patient should select a food high in potassium such as broccoli.

The nurse enters a client's room to complete discharge preparations and finds the client in tears. The client states that someone from the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action? A) Call the family to ask about the payment. B) Continue the client's discharge process. C) Resume the discharge when payment occurs. D) Notify the healthcare provider of the situation.

B) Continue the client's discharge process. - Detaining someone against one's wishes, such as physically or emotionally preventing a client from leaving a healthcare facility, is false imprisonment, which is an intentional tort. To prevent infringement of the clients' rights, the best action for the nurse is to continue the client's discharge preparations (B). Although (A, C, and D) may be options made by the client, the nurse should convey that the client is free to be discharged as prescribed.

A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? A) Insert N/G tube for gastric lavage. B) Determine the child's pulse and respirations. C) Assess the child's level of consciousness. D) Administer an IV D5/0.25 NS as prescribed.

B) Determine the child's pulse and respirations. - The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to (A). (C and D) should occur after assessing the airway.

An older client is receiving a water-soluble drug that is more than the average dose for a young adult. Which action should the nurse implement first? A) Obtain a prescription for lower medication dosages. B) Determine the drug's serum levels for toxicity. C) Start IV fluids to decrease the serum drug levels. D) Hold the next dosage and notify the health care provider.

B) Determine the drug's serum levels for toxicity. - Older clients usually have a decline in lean body mass and total body water that causes water-soluble drugs to become distributed in fluid compartments, resulting in an increased concentration, so determining the drug's serum level for toxicity should be implemented first (B). Although (A, C, and D) may be indicated, an increased plasma drug level should be the determining factor to consider when water-soluble drugs warrant a reduced dosage in the older client.

A 6-year-old child is admitted to the emergency department with status epilepticus. His parents report that his seizure disorder has been managed with phenytoin (Dilantin), 50 mg PO bid, for the past year. Which drug should the nurse plan to administer in the emergency department? A) Phenytoin (Dilantin) B) Diazepam (Valium) C) Phenobarbital (Luminal) D) Carbamazepine (Tegretol)

B) Diazepam (Valium) - Diazepam (Valium) (B) is the drug of choice for treatment of status epilepticus. (A, C, and D) are used for the long-term management of seizure disorders but are not as useful in the emergency management of status epilepticus.

A client with a diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work with whom money has been stolen. The client presently is facing criminal charges. Which behavior indicates that the client is meeting treatment goals? A) Expression of feelings of resentment toward the employer B) Discussion of plans for each of the possible outcomes of a trial C) Expression of resignation about difficult spousal and children relationships D) Discussion of the decision to file a grievance against the employer after discharge from the hospital

B) Discussion of plans for each of the possible outcomes of a trial

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? A) Rapid, thready pulse B) Distended jugular veins C) Elevated hematocrit level D) Increase serum sodium level

B) Distended jugular veins

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A) If the child's tongue darkens, discontinue the Pepto Bismol immediately. B) Do not give if the child has chickenpox, the flu, or any other viral illness. C) Avoid the use of Pepto Bismol until the child is at least 16 years old. D) Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache."

B) Do not give if the child has chickenpox, the flu, or any other viral illness. - Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.

A nurse is educating a client with a colostomy of the ascending colon about using a colostomy appliance. Which instructions should the nurse provide to help prevent leakage of stool from the appliance? A) Irrigate the colostomy to establish an expected pattern of elimination B) Empty the appliance when it is approximately half full C) Use an antiseptic to clean the peristomal skin before applying the appliance D) Select an appliance with a pouch opening of at least 5 cm or larger than the stoma

B) Empty the appliance when it is approximately half full

A client is admitted with anorexia, weight loss, abdominal distension, and abnormal stools. A diagnosis of malabsorption syndrome is made. What nursing action should the nurse implement to best meet this client's needs? A) Allow the client to eat food preferences B) Encourage the consumption of high-protein foods C) Institute IV therapy to improve the client's hydration D) Maintain NPO status because food precipitates diarrhea

B) Encourage the consumption of high-protein foods

Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription? A) As needed. B) Every 12 hours. C) Every 24 hours. D) Every 4 to 6 hours.

B) Every 12 hours. - A controlled-release oxycodone provides long-acting analgesia to relieve moderate to severe pain, so a dosing schedule of every 12 hours (B) provides the best around-the-clock pain management. Controlled-release oxycodone is not prescribed for breakthrough pain on a PRN or as needed schedule (A). (C) is inadequate for continuous pain management. Using a schedule of every 4 to 6 hours (D) may jeopardize patient safety due to cumulative effects.

A nurse is planning a community health program about screening for cancer. Which information recommended by the American Cancer Society (ACS) should the nurse include? A) Mammography should be performed annually after age 35 years for women B) Fecal occult blood testing should be performed yearly beginning at age 50 years C) Breast self-examination should be performed monthly beginning at age 30 years D) Digital rectal exams and PSA testing should be done yearly after age 40 for men

B) Fecal occult blood testing should be performed yearly beginning at age 50 years

What clinical indicators should a nurse identify when assessing a client with pyrexia (fever)? Select all that apply. A) Dyspnea B) Flushed face C) Precordial pain D) Increased pulse rate E) Increased blood pressure

B) Flushed face D) Increased pulse rate

A nurse is caring for a client who is receiving serum albumin. What therapeutic effect does the nurse anticipate? A) Improved clotting of blood B) Formation of RBC C) Activation of WBC D) Maintenance of oncotic pressure

B) Formation of RBC

The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A) Tachypnea B) Guaiac-positive stool C) Multiple small abdominal bruises D) Dependent pitting edema

B) Guaiac-positive stool - Fragmin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding, such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed. (A) is not an indication to hold the medication unless accompanied by signs of bleeding. (C) is an expected result. (D) is related to fluid volume, rather than anticoagulant therapy.

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A) Fluid and electrolyte balance is maintained. B) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. D) Normal bowel patterns are reestablished.

B) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. - A priority goal for the client with infectious diarrhea caused by Clostridium difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission (B). (A and C) are goals dependent on the return of the client's normal bowel pattern (D).

During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment, a CBC and a urinalysis are performed. Which laboratory finding should alert the nurse that further assessment is required? A) WBC count of 90000/mm B) Hemoglobin level of 10 g/dL C) Urine specific gravity of 1.020 D) Glucose level of 1+ in the urine

B) Hemoglobin level of 10 g/dL - This hemoglobin level is abnormally low. The WBC count and urine specific gravity are normal values. A glucose level of 1+ in the urine is normal during pregnancy.

A child is being treated with mebendazole (Vermox) for pinworms. Which type of diet should the mother be instructed to feed the child while the child is receiving this medication? A) Lactose-free foods B) High-fat diet C) Vitamin C-enriched foods D) High-fiber diet

B) High-fat diet - A high-fat diet increases the absorption of mebendazole (Vermox), which boosts the effectiveness of the medication in eliminating the pinworms (B). (A, C, and D) are not related to the administration of this medication.

A male client with degenerative arthritis of the knees and hips takes an over-the-counter (OTC) nonsteroidal antiinflammatory drug (NSAID) for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get to sleep, I find that I wake up a number of times during the night." Which information should the nurse obtain first? A) Does the client snore or experience sleep apnea? B) How intense does the client rate his pain on a scale of 1 to 10? C) What type of medications does the client take before bedtime? D) Are there any white noise or lights on during the night?

B) How intense does the client rate his pain on a scale of 1 to 10? - A client with degenerative arthritis may have sleep disturbances related to chronic pain, so the client's pain intensity (B) should be determined. Other factors that may affect the client's sleep patterns (A, C, and D) should be considered after assessing the client's arthritic pain and how it is managed.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A) Hyperexcitability of reflexes B) Hyperextension of the head and back C) Inability to flex the chin to the chest D) Lateral facial paralysis

B) Hyperextension of the head and back - Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve.

A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbalance should the nurse monitor in this client? A) Hypokalemia B) Hypocalcemia C) Hypernatremia D) Hyperglycemia

B) Hypocalcemia

During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect and what suggestion is made to correct it? A) Hypercalcemia and tell her to avoid eating hard cheese B) Hypocalcemia and tell her to increase her intake of milk C) Hyperkalemia and tell her to consult with her HCP D) Hypokalemia and tell her to increase her intake of green, leafy vegetables

B) Hypocalcemia and tell her to increase her intake of milk - Low calcium causes leg cramps.

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A) Diabetes insipidus B) Hypotension C) Hyperkalemia D) Uremia

B) Hypotension - During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension (B). (A) is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not (C). (D) is characteristic of chronic renal failure with multiple body system involvement.

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? A) Exploring the client's emotional conflict B) Identifying personal feelings toward this client D) Planning to discuss this with the client's family D) Developing a rapport with the client's healthcare provider

B) Identifying personal feelings toward this client - Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? A) Decreased blood supply B) Impaired neural functioning C) Perforation of the bowel wall D) Obstruction of the bowel lumen

B) Impaired neural functioning

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. Who should be the witness? A) Nursing supervisor B) LPN C) Client's health care provider D) Designated nursing assistant

B) LPN - The wasting of controlled substances should be witnessed by two licensed personnel according to federal regulations; this can be done by an RN or a LPN.

The nurse educator is teaching the nursing staff about a new computerized documentation system that is recently implemented. What information is the best indication that the education is effective? A) A decrease in number of calls to the technology department. B) Less time for nursing staff to complete the daily charting. C) An increase in staff acceptance of computerized charting. D) An improvement from pretest scores of the training session.

B) Less time for nursing staff to complete the daily charting. - Being able to use the system to accomplish charting more efficiently and in less time (B) compared to previous documentation techniques indicates the staff has learned how to use the system effectively. (A) may be related to technology functionality and is not related to effective user learning. Acceptance (C) does not indicate that the staff understand or can use the system correctly. (D) measures cognition but not application.

An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation? A) Minimize environmental stress to reduce confusion B) Let the client continue to think in his or her own way C) Prompt the client to recognize the correct date and time D) Ask the client to recall the past to understand the present situation

B) Let the client continue to think in his or her own way - Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in his or her own way. Minimizing environmental stress can help to reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.

The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A) Reports feelings of sadness B) Mood changes from depressed to happy C) Begins giving away possessions D) Becomes compliant with medication regimen E) Independently joins a support group

B) Mood changes from depressed to happy C) Begins giving away possessions - Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide (B and C). Feelings of sadness are signs of depression but not impending suicide (A). (D and E) are not typically indicative of impending suicide

A client with HIV who was recently diagnosed with tuberculosis (TB) asks the nurse, "Why do I need to take all of these medications for TB?" What information should the nurse provide? A) Antiretroviral medications decrease the efficacy of the TB drugs. B) Multiple drugs prevent the development of resistant organisms. C) Duration of the medication regimen is shortened. D) Potential adverse drug reactions are minimized.

B) Multiple drugs prevent the development of resistant organisms. - A multidrug regimen is prescribed for a client with HIV and TB to prevent the development of resistance of the tubercle bacilli (B). Although antitubercular medications can inhibit some antiretrovirals (A), a multidrug regimen is needed to inhibit the proliferation of the virulent tubercle bacilli. The duration of antitubercular therapy is typically 6 to 9 months and is not shortened (C) by the use of multiple medications. A client who is receiving HIV and TB therapy is at an increased risk of adverse reactions (D) because of the complex medication regimens and complications secondary to immunosuppression.

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply. A) Chovek sign B) Muscle cramps C) Extreme fatigue D) Cardiac dysrhythmias E) Increased temperature

B) Muscle cramps C) Extreme fatigue

A client who had a suprapubic prostatectomy returns from the PACU and accidentally pulls out the urethral catheter. What should the nurse do first? A) Reinsert a new catheter B) Notify the HCP C) Check for bleeding by irrigating the suprapubic catheter D) Take no immediate action if the suprapbuic tube is draining

B) Notify the HCP

A nurse is caring for a male client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply. A) Polyuria B) Obese trunk C) Hypotension D) Sleep disturbance E) Thin arms and legs

B) Obese trunk D) Sleep disturbance E) Thin arms and legs

The apical heart rate of an infant receiving digoxin (Lanoxin) for congestive heart failure is 80 beats/min. Which intervention should the nurse implement first? A) Administer the next dose of digoxin as scheduled. B) Obtain a serum digoxin level. C) Administer a PRN dose of atropine sulfate. D) Assess for S3 and S4 heart sounds.

B) Obtain a serum digoxin level. - Sinus bradycardia (rate < 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level is the highest priority (B). Further doses of digoxin should be withheld until the serum level is obtained (A). (C) is not indicated unless the client exhibits symptoms of diminished cardiac output. (D) provides information about cardiac function but is of less priority than (B).

A nurse determines that a postpartum client is gravida 1 and para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care? A) Type and crossmatch blood B) Obtain an order for RhoGAM C) Determine the father's blood type D) Observe for signs of ABO incompatibility

B) Obtain an order for RhoGAM

The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort? A) Increase fluid intake. B) Offer high-protein foods. C) Provide a high-residue diet. D) Give prompt mouth care.

B) Offer high-protein foods. - Measures to manage nausea and vomiting include the use of antiemetics and avoiding foods and liquids that increase stomach acidity, such as coffee, milk, and citrus acid juices. For some clients, an empty stomach exacerbates the nausea, so offering frequent, small amounts of foods that appeal to the client, such as dry cracker or bland, high protein foods (B), help maintain nutritional status. Although (A and C) may help prevent constipation or diarrhea, the best action is to meet the client's basic needs for hydration and nutrition. Although (D) is a comfort measure that minimizes nausea, the presence of protein in the stomach may be more effective.

A client is being admitted for total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation has been completed? Select all that apply. A) After reporting severe pain B) On admission to the hospital C) Upon entering the OR D) Before transfer to a rehabilitation unit E) At the time of scheduling for the surgical procedure

B) On admission to the hospital D) Before transfer to a rehabilitation unit

A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client? A) Tolerance to the drugs develops readily B) One third to one half the usual dose should be prescribed C) Opioids may interfere with the secretion of thyroid hormones D) Sedation will have a paradoxical effect, causing hyperactivity

B) One third to one half the usual dose should be prescribed - Patients with myxedema have an increased sensitivity to opioids and need less of a drug.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? A) The dosage is kept at a minimum B) Only a small part of the body is eradicated C) The client's physical condition is not a risk factor D) Nutritional environment of the affected cells is a risk factor

B) Only a small part of the body is eradicated

Which physiologic mechanism explains a drug's increased metabolism that is triggered by a disease process? A) Selectivity response B) Pharmacokinetics C) Pharmacodynamics D) Pharmacotherapeutics

B) Pharmacokinetics - Pharmacokinetics (B) describes the physiologic process of a drug's movement throughout the body and how the drug's interaction is affected by an underlying disease. Selectivity (A), or a selective drug, is defined as a drug that elicits only the response for which it is given. Pharmacodynamics (C) is the impact of drugs on the body. Pharmacotherapeutics (D) is defined as the use of drugs to diagnose, prevent, or treat disease or prevent pregnancy.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A) Assign an unlicensed assistive personnel to transport the client via a wheelchair. B) Remind the client to walk carefully down the stairs until reaching a lower floor. C) Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D) Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

B) Remind the client to walk carefully down the stairs until reaching a lower floor. - During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully (B). Ambulatory clients do not require the assistance of a wheelchair to be evacuated (A). Elevators (C) should not be used during a fire and fire doors should be kept closed (D) to help contain the fire.

A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles? A) Moderate exercise and low fat intake. B) Rest and increased carbohydrate intake. C) Intense exercise and decreased carbohydrate intake. D) Intense exercise and high intake of complex carbohydrates.

B) Rest and increased carbohydrate intake. - Carbohydrate loading is the process of changing foods eaten and adjusting exercise intensity to increase glycogen stores in the muscle. To achieve maximum muscle glycogen stores, a high carbohydrate diet should be consumed as part of a regular exercise program (60%-70% of total kilocalories from carbohydrate that tapers off to allow muscles to rest (B). (A, C, and D) do not balance the client's exercise intensity with an intake of high complex carbohydrates needed to provide maximum glycogen stores to maintain muscular conditioning.

A nurse is caring for a client who has a radioactive implant for cancer of the cervix. What is the priority nursing action? A) Store urine in lead-lined containers B) Restrict visitors to a 10 minute stay C) Wear a lead-lined apron when giving care D) Avoid giving injections in the gluteal muscle

B) Restrict visitors to a 10 minute stay

A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse? A) Place the client in restraints B) Sedate and place the client in a controlled environment C) Encourage the client to play Ping Pong with another client D) Set firm limits on the client's behavior and enforce adherence to them

B) Sedate and place the client in a controlled environment

After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse implement? A) Complete an incident report. B) Select another sterile needle. C) Disinfect the needle with an alcohol swab. D) Notify the supervisor of the department immediately

B) Select another sterile needle. - After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a needle with an alcohol swab (C) is not in accordance with standards for safe practice and infection control.

A client at 16 weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her he has genital herpes. What should the nurse include when teaching the client about sexual activity? A) Condoms must be used when having intercourse B) Sexual abstinence should be practiced during the last six weeks C) It will be necessary to refrain from sexual contact during pregnancy D) Meticulous cleaning of the vaginal area after intercourse is essential

B) Sexual abstinence should be practiced during the last six weeks - This will help prevent transmission to the baby.

A client with the diagnosis of cancer of the stomach expresses aversion to meals and eats only small amounts. What should the nurse provide? A) Nourishment between meals B) Small portions more frequently C) Supplementary vitamins to stimulate the client's appetite D) Only foods the client likes in small portions at mealtimes

B) Small portions more frequently

While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be? A) Continue observing the vaccination. B) Stop the nurse from giving the vaccination C) Give the nurse a povidone-iodine (Betadine) swab to use instead. D) Notify the members of the team about the need to use antiseptic swabs.

B) Stop the nurse from giving the vaccination - Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site. Observation is insufficient; the nurse manager must intervene to ensure that the vaccine is given using the correct technique. Povidone-iodine will deactivate the smallpox vaccine. The site should be dry before administering the vaccine.

A nurse is caring for a client with CBI. Which is the most important nursing action? A) Monitoring USG to determine hydration B) Subtracting irrigant from output to determine the urine volume C) Recording UO every hour to determine kidney function D) Obtaining a 24 hour urine specimen to determine urine concentration

B) Subtracting irrigant from output to determine the urine volume

A nurse is teaching a client with diabetes about the treatment of hypoglycemia. The nurse knows that teaching was effective if the client picks which foods to treat a hypoglycemic attack? A) Fruit juice and a lollipop. B) Sugar and a slice of bread. C) Chocolate candy and a banana. D) Peanut butter crackers and a glass of milk.

B) Sugar and a slice of bread. - The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); the simple sugar elevates the blood glucose level rapidly; the complex carbohydrates and protein produce a more sustained response. Fruit juice and a lollipop are fast-acting sugars, and neither of them will provide a sustained response. The fat content of chocolate candy decreases the rate of absorption of glucose. Neither peanut butter crackers nor a glass of milk is a fast-acting sugar; peanut butter crackers and milk can be used to maintain the glucose level after it is raised.

After many years of coping with colitis, a client makes the decision to have a colectomy as advised by the HCP. Which is most likely the significant factor that impacted the client's decision? A) It is temporary until the colon heals B) Surgical treatment cures UC C) UC can progress to Crohn's disease D) Without surgery, eating table foods is contraindicated

B) Surgical treatment cures UC

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A) Inspect the dressing over the puncture site and under the client for bleeding. B) Take the vital signs to determine the client's response for a potential blood loss. C) Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D) Assess the client's pain level to determine the need for analgesic medication.

B) Take the vital signs to determine the client's response for a potential blood loss. - After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure (B). Although (A, C, and D) should be implemented after the procedure, the first action is to obtain a baseline assessment.

A toddler screams and cries nosily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 - 45 minutes. Legally, how should this behavior be interpreted? A) Limits had to be set to control the child's crying B) The child had a right to remain in the room with the other children C) The child had to be removed because the other children needed to be considered D) Segregation of the child for more than half an hour was too long a period of time

B) The child had a right to remain in the room with the other children

A nurse is responding to the needs of victims at a collapsed building. WHat principle guides the nurse's priorities during this disaster? A) Hemorrhage necessitates immediate care to save the most lives B) Those requiring minimal care are treated first so they can help others C) Victims with head injuries are treated first because they are the most complex D) Children receive the higher priority because they have the greatest life expectancy

B) Those requiring minimal care are treated first so they can help others

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity?" A) Poor nutrition. B) Tissue ischemia. C) Prolonged illness or disease. D) Nitrogen build-up in the underlying tissues.

B) Tissue ischemia. - Prolonged, intense pressure affects cellular metabolism by impeding capillary blood flow to tissue over weight-bearing bony prominences, resulting in tissue ischemia (B), skin breakdown, and tissue death. Although key factors contributing to pressure ulcers include poor nutrition (A), prolonged illness or disease (C), and build-up of metabolic nitrogen in underlying tissues (D), tissue ischemia is the primary factor in pressure ulcer development.

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? A) Pulse rate B) Tissue turgor C) Specific gravity D) Body temperature

B) Tissue turgor

A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? A) Femoral pulse B) Toes for mobility C) Condition of the pin D) Range of motion of the knee

B) Toes for mobility

A person sustains deep-partial thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. THe nurse advises the person to go to a HCP if: A) Blisters appear B) Urinary output decreases C) Edema and redness occur D) Low-grade fever develops

B) Urinary output decreases - A decrease in urinary output in a patient with burns indicates hypovolemia and must be treated immediately. Blisters, and edema and redness are expected. A low-grade fever is not as concerning as a decreased urinary output.

An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary healthcare provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of the treatment? A) Urine output of 10 L/day B) Urine specific gravity less than 1.025 C) Urine osmolarity of 80 mOsm/kg (80 mmol/kg) D) Serum osmolarity of 600 mOsm/kg (600 mmol/kg)

B) Urine specific gravity less than 1.025 - Because the specific gravity is less than 1.025 after treatment, the outcome is considered positive. In syndrome of inappropriate antidiuretic hormone (SIADH), the specific gravity is greater than 1.025. Small cell lung cancer is a risk factor of SIADH. Muscle cramping, thirst, and fatigue are clinical manifestations of SIADH. A serum osmolarity of 600 mOsm/kg indicates central diabetes insipidus. A urine output 10 L/day and a urine osmolarity of 80 mOsm/kg indicate diabetes insipidus.

A psychiatric client is discharged from the hospital with a prescription for haloperidol (Haldol). Which instruction should the nurse include in the discharge teaching plan for this client? A) Take with antacids to reduce gastrointestinal irritation. B) Use sunglasses and sunscreen when outdoors. C) Eat foods low in fiber and salt. D) Count the pulse before each dose.

B) Use sunglasses and sunscreen when outdoors. - Photosensitivity is a common adverse effect of haloperidol (Haldol); therefore, the use of sunglasses and sunscreen (B) should be included in the discharge teaching for this client. (A, C, and D) are not pertinent to client teaching regarding the use of haloperidol (Haldol).

A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication? A) Euphoria. B) Vomiting. C) Hypertension. D) Hypoventilation.

B) Vomiting. - A disulfiram reaction includes nausea and severe vomiting (B), if alcohol is ingested while taking disulfiram (Antabuse). (A, C, and D) are not typically associated with the combined use of disulfiram and alcohol.

Which symptoms are serious adverse effects of beta-adrenergic blockers such as propranolol (Inderal)? A) Headache, hypertension, and blurred vision. B) Wheezing, hypotension, and AV block. C) Vomiting, dilated pupils, and papilledema. D) Tinnitus, muscle weakness, and tachypnea.

B) Wheezing, hypotension, and AV block. - (B) represents the most serious adverse effects of beta-blocking agents. AV block is generally associated with bradycardia and results in potentially life-threatening decreases in cardiac output. Additionally, wheezing secondary to bronchospasm and hypotension represent life-threatening respiratory and cardiac disorders. (A, C, and D) are not associated with beta-blockers.

The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.Administer aspirin with tissue plasminogen activator (t-PA). B.Complete the National Institute of Health Stroke Scale (NIHSS). C.Assess the client for signs of bleeding during and after the infusion. D.Start t-PA within 6 hours after the onset of stroke symptoms. E.Initiate multidisciplinary consult for potential rehabilitation.

B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

Which intervention(s) should the nurse implement when administering a new prescription of amitriptyline HCl (Elavil) to a client with a depressive disorder? (Select all that apply.) A.Explain that therapeutic effects should be achieved within 1 to 3 days. B.Administer at bedtime to minimize sedative effects. C.Give 1 hour after the administration of isocarboxazid (Marplan). D.Take blood pressure prior to and after administration. E.Assess for adverse reactions such as dry mouth and blurred vision.

B,D,E Rationale: The drug causes sedation, so it should be given at bedtime (B). Cardiovascular adverse reactions include orthostatic hypotension; therefore, the blood pressure should be assessed (D). This drug can cause anticholinergic effects such as dry mouth, blurred vision, constipation, and urinary retention (E). The drug takes 2 to 6 weeks to achieve therapeutic effects (A). All monoamine oxidase (MAO) inhibitors such as isocarboxazid should be discontinued 1 to 3 weeks prior to the administration of Elavil (C).

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?

B.While the nurse is taking the client's blood pressure, he has a carpal spasm

277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?

Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A).

159. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Be alert for possible cross-sensitivity to cephalosporin agents.

514. A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?

Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?

Bed rest with elevation of the affected extremity

288. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begin to show signs of improvement in affect

62. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

Bilateral Wheezing.

488. A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client?

Blood pressure 149/101

445. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse?

Blood pressure 170/98

136. After a routine physical examination, the healthcare provider admits a woman with a history of SLE to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment findings warrant immediate intervention by the NURSE? a) Blood pressure 170/98. b) Joint and muscle aches. c) Urine output 300ml/hour. d) Dark, rust colored urine.

Blood pressure 170/98.

474. Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)?

Body mass index

75. The nurse enters the room of a disoriented female client to supervise the care being provided by an unlicensed assistive personnel (UAP). The UAP has left the room to obtain linens, leaving the client supine and lying on wet sheets, with side rails down and the bed in the high position. Which action should the nurse implement first? a) Explain risks of the client's unsafe situation to the UAP b) The client should be re-oriented to her surroundings c) Both upper side rails of the bed should be raised d) Place the client in lateral position off the wet linens

Both upper side rails of the bed should be raised

148. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

Bowel patterns

A family of a client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the nurse's best response? A) "Medications will mask the signs of the disease." B) "With continuous treatment, the progression of the disease can usually be controlled." C) "There will be periods when bed rest will be necessary and times when regular activity will be possible." D) "The progression generally is slow, so people with myasthenia will spend their younger life with few problems."

C) "There will be periods when bed rest will be necessary and times when regular activity will be possible."

A couple indicate that they do not want any more children. The woman is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in the preoperative teaching? A) "Menstruation will stop after the surgery." B) "Birth control will be needed until your follow-up appointment." C) "You will be admitted as an outpatient for same-day surgery."

C) "You will be admitted as an outpatient for same-day surgery."

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? A) 1 - 2 hours B) 3 - 4 hours C) 10 - 12 hours D) 24 - 48 hours

C) 10 - 12 hours

When teaching irrigation of a colostomy, how many inches above the stoma should the nurse teach the client to hold the container? A) 15 cm (6 inches) B) 25 cm (10 inches) C) 30 cm (12 inches) D) 45 cm (18 inches)

C) 30 cm (12 inches)

Which pediatric client requires immediate intervention by the nurse? A) A 2-year-old with a twenty-four hour urinary output of 500 ml. B) A 3-year-old with several episodes of nocturnal enuresis. C) A 4-year-old with an easily palpable bladder and frequency. D) A 5-year-old with diuresis following furosemide (Lasix) administration

C) A 4-year-old with an easily palpable bladder and frequency. - Frequency and bladder distention (C) are indications of urinary retention, which requires immediate intervention by the nurse. (A) is the normal output for a child of this age. (B) describes bed-wetting, not uncommon in a child of this age, although if the problem persists in a child older than 5 years of age, further assessment and intervention is warranted. (D) is an expected response to the medication, which requires routine monitoring, but does not indicate a need for immediate intervention.

A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway? A) Tracheostomy tube insertion. B) An endotracheal tube. C) A nasopharyngeal tube. D) An oral airway.

C) A nasopharyngeal tube. - If head and neck injuries are suspected, a client with a GCS of 6 who demonstrates motor flexion in response to painful stimuli requires airway maintenance without risk of compromise to spinal cord function. Nasal intubation using a nasopharyngeal tube (C) is the airway of choice for a client with suspected spinal cord injury because less cervical spine manipulation is needed during insertion, as compared with endotracheal intubation (B). A tracheostomy (A) is an option if long-term artificial airway maintenance is needed. Although (D) maintains an open airway by keeping the tongue out of the way, neck hyperextension and spinal manipulation pose a risk for spinal cord damage.

The family of an older adult who is aphasic reports to the nurse manager that the primary care nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? A) Procedure for a client's benefit do not require a signed consent B) Clients who are aphasic are incapable of signing informed consent C) A separate signed informed consent for routine treatments is necessary D) A specific intervention without a client's signed consent is an invasion of rights

C) A separate signed informed consent for routine treatments is necessary - This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission.

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A) A trial of adrenocorticotrophic hormone injections. B) Frequent stimulation of the cremasteric reflex. C) A trial of human chorionic gonadotrophic hormone. D) Frequent warm baths to gently dilate the scrotal area.

C) A trial of human chorionic gonadotrophic hormone. - A trial of HCG (human chorionic gonadotrophic hormone) (C) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex. (A) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may relax the cremasteric muscle, but may not cause the testes to descend.

A nurse is caring for a client admitted to the hospital for DKA. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply. A) Sweating B) Retinopathy C) Acetone breath D) Increased arterial bicarbonate level E) Decreased arterial CO2 level

C) Acetone breath E) Decreased arterial CO2 level

A client with an inflamed sciatic nerve is to have a conventional TENS device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? A) Maintain the settings programmed by the HCP B) Turn the machine on several times a day for 10 - 20 min C) Adjust the dial on the unit until the client states that pain is relieved D) Apply the color-coded electrodes to the client where they are most comfortable

C) Adjust the dial on the unit until the client states that pain is relieved

A client is taking hydromorphone (Dilaudid) PO q4h at home. Following surgery, Dilaudid IV q4h PRN and butorphanol tartrate (Stadol) IV q4h PRN are prescribed for pain. The client received a dose of the Dilaudid IV four hours ago, and is again requesting pain medication. What intervention should the nurse implement? A) Alternate the two medications q4h PRN for pain. B) Alternate the two medications q2h PRN for pain. C) Administer only the Dilaudid q4h PRN for pain. D) Administer only the Stadol q4h PRN for pain.

C) Administer only the Dilaudid q4h PRN for pain. - Dilaudid is an opioid agonist. Stadol is an opioid agonist-antagonist. Use of an agonist-antagonist for the client who has been receiving opioid agonists may result in abrupt withdrawal symptoms, and should be avoided (C). (A, B, and D) do not reflect good nursing practice.

A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take? A) Dispense a tetanus antitoxin. B) Prepare human tetanus immune globulin. C) Administer tetanus toxoid booster. D) Delay the tetanus toxoid booster until due.

C) Administer tetanus toxoid booster. - After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B, and D) are not indicated.

For which client(s) should the nurse withhold the initial dose of a cyclooxygenase 2 (COX-2) inhibitor until notifying the health care provider? (Select all that apply.) A) A middle-aged adult with a history of tinnitus while taking aspirin B) A middle-aged adult with a history of polycystic ovarian disease C) An older adult with a history of a skin rash while taking glyburide (DiaBeta) D) An adolescent with a history of an anaphylactic reaction to penicillin E) An older adult with a history of gastrointestinal upset while taking naproxen sodium (Naprosyn) F) An adolescent at 34 weeks of gestation experiencing 1+ pitting edema

C) An older adult with a history of a skin rash while taking glyburide (DiaBeta) D) An adolescent with a history of an anaphylactic reaction to penicillin F) An adolescent at 34 weeks of gestation experiencing 1+ pitting edema - COX-2 inhibitors are contraindicated for those who are allergic to sulfa drugs (C), aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs). Drug safety for adolescents (D and F) is not yet established, and COX-2 inhibitors, as well as NSAIDs, are contraindicated during the third trimester of pregnancy (F) because they can cause a premature closure of the patent ductus arteriosus. Tinnitus, an adverse reaction of aspirin (A), and ovarian disease (B) are not contraindications for the use of COX-2 inhibitors. Gastrointestinal upset is a common adverse reaction of NSAIDs (E) but is not a contraindication for the use of a COX-2 inhibitor.

A client has an anaphylactic reaction after receiving IV penicillin. What does the nurse conclude is the cause of this reaction? A) An acquired atopic sensitization occurred B) There was passive immunity to the penicillin allergies C) Antibodies to penicillin developed after a previous exposure D) Potent antibodies were produced when the infusion was instituted

C) Antibodies to penicillin developed after a previous exposure

A client with ARDS is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? A) Regulate the PEPP according to the rate and depth of the client's respirations B) Deflate the cuff on the endotracheal tube for a few minutes every one to two hours C) Assess the need for suctioning when the high pressure alarm is activated D) Adjust the temperature of fluid in the humidification chamber, depending on the volume of gas delivered

C) Assess the need for suctioning when the high pressure alarm is activated

The nurse is preparing to apply a surface anesthetic agent for a client. Which action should the nurse implement to reduce the risk of systemic absorption? A) Apply the anesthetic to mucous membranes. B) Limit the area of application to inflamed areas. C) Avoid abraded skin areas when applying the anesthetic. D) Spread the topical agent over a large surface area.

C) Avoid abraded skin areas when applying the anesthetic. - To minimize systemic absorption of topical anesthetics, the anesthetic agent should be applied to the smallest surface area of intact skin (C). Application to the mucous membranes poses the greatest risk (A) of systemic absorption because absorption occurs more readily through mucous membranes than through the skin. Inflamed areas generally have an increased blood supply, which increases the risk of systemic absorption, so (B) should be avoided. A large surface area increases the amount of topical drug that is available for transdermal absorption, so the smallest area should be covered, not (D).

A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A) Pain scale B) Vital signs C) Breath sounds D) Level of consciousness

C) Breath sounds - Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds (C). (A, B, and D) are important assessment data but are not specifically related to insertion of a central venous catheter.

A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted by transfusions?" The nurse should response, "Although the risk is minimal, the type of hepatitis associated with blood transfusions is hepatitis: A) A B) B C) C D) D

C) C

When performing a newborn assessment after a vaginal birth, a nurse observes a swelling on one side of the top of the head. What clinical manifestation did the nurse identify? A) Caput succedaneum that will spread across the scalp and then resolve B) Fontanelle that bulges when the infant cries and then will close in eighteen months C) Cephalohematoma that does not cross the suture line and will resolves in several weeks D) Molding that results from the skull taking the shape of the vagina and will disappear in several days

C) Cephalohematoma that does not cross the suture line and will resolves in several weeks - This is a description of a cephalohematoma because it is only on one side of the head and does not cross the suture line.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. A) Gently insert the catheter without suction using sterile technique. B) Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). C) Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. D) Apply suction intermittently while withdrawing the catheter.

C) Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. B) Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). A) Gently insert the catheter without suction using sterile technique. D) Apply suction intermittently while withdrawing the catheter. - Equipment should be set up and adjusted prior to beginning the procedure (C). Hyperoxygenation using an MRB should be completed prior to inserting the catheter (B). After preoxygenation, the catheter can be inserted (A) and suction can be applied intermittently (D).

Which factor is most important to ensure compliance when planning to teach a client about a drug regimen?A. A) Genetics B) Client age C) Client education D) Absorption rate

C) Client education - The client's educational level (C) is the most important factor when planning teaching to ensure a client's compliance with taking a prescribed drug. (A and D) are physiologic responses that do not relate to a client's compliance. Although maturity level and age (B) contribute to compliance, the client's basic understanding of instructions, which is best indicated by educational level, is more significant.

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes: A) Onset of the disease is slow B) Excessive weight is a contributing factor C) Complications are not present at the time of diagnosis D) Treatment involves diet, exercise and oral medications

C) Complications are not present at the time of diagnosis - Clinical presentation of type 1 diabetes is characterized by ACUTE (ABRUPT) onset, and therefore there is no time to develop the long-term complications that are common with long-standing disease.

A postoperative client has been receiving a continuous IV infusion of meperidine (Demerol) 35 mg/hr for four days. The client has a PRN prescription for Demerol 100 mg PO q3h. The nurse notes that the client has become increasingly restless, irritable and confused, stating that there are bugs all over the walls. What action should the nurse take first? A) Administer a PRN dose of the PO meperidine (Demerol). B) Administer naloxone (Narcan) IV per PRN protocol. C) Decrease the IV infusion rate of the meperidine (Demerol) per protocol. D) Notify the healthcare provider of the client's confusion and hallucinations.

C) Decrease the IV infusion rate of the meperidine (Demerol) per protocol. - The client is exhibiting symptoms of Demerol toxicity, which is consistent with the large dose of Demerol received over four days. (C) is the most effective action to immediately decrease the amount of serum Demerol. (A) will increase the toxic level of medication in the bloodstream. Naloxone (B) is an opioid antagonist that is used during an opioid overdose, but it is not beneficial during Demerol toxicity and can precipitate seizures. The healthcare provider should be notified (D), but that is not the initial action the nurse should take; first the amount of drug infusing should be decreased.

A client with viral influenza is receiving vitamin C, 1000 mg PO daily, and acetaminophen elixir, 650 mg PO every 4 hours PRN. The nurse calls the health care provider to report that the client has developed diarrhea. Which change in prescriptions should the nurse anticipate? A) Change the acetaminophen to ibuprofen. B) Change the elixir to an injectable route. C) Decrease the dose of vitamin C. D) Begin treatment with an antibiotic.

C) Decrease the dose of vitamin C. - Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C (C). Acetaminophen does not cause diarrhea (A) and is not available in an injectable form (B). Because the client has a viral infection, (D) will not be beneficial.

Which drug can cause diabetes insipidus? A) Cabergoline B) Metyrapone C) Demeclocycline D) Aminoglutethimide

C) Demeclocycline - Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

588. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take?

Perform a sterile vaginal exam

The health care provider prescribes the anticonvulsant carbamazepine (Tegretol) for an adolescent client with a seizure disorder. The nurse should instruct the client to notify the health care provider if which condition occurs? A) Experiences dry mouth B) Experiences dizziness C) Develops a sore throat D) Develops gingival hyperplasia

C) Develops a sore throat - Blood dyscrasias (aplastic anemia, leukopenia, anemia, and thrombocytopenia) can be an adverse effect of carbamazepine (Tegretol). Flulike symptoms (C), such as pallor, fatigue, sore throat, and fever, are indications of such dyscrasias. (A and B) are expected reactions. (D) is a side effect of phenytoin (Dilantin), not carbamazepine (Tegretol).

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. A) Tetany B) Seizures C) Diarrhea D) Weakness E) Dysrhythmias

C) Diarrhea D) Weakness E) Dysrhythmias

A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" What information should the nurse include in response to this question? A) Malignant growth B) Pocked of undigested food particles C) Dilated space of necrotic tissue and blood D) Sack filled with fluid and pancreatic enzymes

C) Dilated space of necrotic tissue and blood

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A) Perform cough and deep breathing exercises hourly. B) Turn from side to side in bed at least every 2 hours. C) Dorsiflex and plantarflex the feet 10 times each hour. D) Drink approximately 4 ounces of water every hour.

C) Dorsiflex and plantarflex the feet 10 times each hour. - To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion (C). (A, B, and D) are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than (C).

The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting? A) Encourage child to cough to raise the secretions before suctioning. B) Allow child to rest after every five times the suction catheter is passed. C) Each pass of the suction catheter should take no longer than five seconds. D) Select a catheter 3/4 the size of the diameter of the tracheostomy tube.

C) Each pass of the suction catheter should take no longer than five seconds. - To ensure the child's O2 saturation returns to normal, suctioning of the tracheostomy should last no more than five seconds per aspiration (C) and rest periods provided after each aspiration, not (B). (A) is not effective. To facilitate ease of insertion and prevent tracheal wall abrasion, the suction catheter should be half the diameter of the tracheostomy tube, not (D).

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A) Encourage the client to turn from side to side every 2 hours. B) Elevate the foot of the client's bed at least 6 inches. C) Encourage the client to ambulate every 3 hours. D) Teach the client how to perform leg exercises while in bed.

C) Encourage the client to ambulate every 3 hours. - Ambulation is the best way to increase peripheral vascular activity (C). (A, B, and D) will increase peripheral vascular activity but are not as effective as ambulation.

Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply). A) Adhere to strict time limits for activities. Incorrect B) Give all instructions at the start of the activity. C) Encourage verbal and nonverbal communication. Correct D) Speak to the client in a loud and clear voice. E) Maintain a calm demeanor during all interactions. Correct

C) Encourage verbal and nonverbal communication. E) Maintain a calm demeanor during all interactions. - Alzheimer's causes the client to experience cognitive deficits and memory impairment, so frequent communication (C) and a calm affect (E) should be maintained with the client. (A, B, and D) increases the client's frustration.

A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child's urine for the presence of which consistent? A) Protein B) Glucose C) Erythrocytes D) Lymphocytes

C) Erythrocytes - Patients with low platelet counts are at an increased risk for bleeding and will have erythrocytes (RBC) in the urine.

A nurse is collecting information about a client who has type 1 diabetes and who is being admitted because of diabetic ketoacidosis coma. Which factors can predispose a client to this condition? Select all that apply. A) Taking too much insulin B) Getting too much exercise C) Excessive emotional stress D) Running a fever with the flu E) Eating fewer calories than prescribed

C) Excessive emotional stress D) Running a fever with the flu -

A client with cancer of the cervix has an intracavitary radioactive sealed implant in place. What precaution should the nurse take to protect against excessive exposure to radiation? A) Dispose of body fluids in special marked containers B) Cohort two clients who have implanted radiation therapy C) Exit the room walking backward while wearing an apron D) Limit visitors to individuals who are 13 years and older

C) Exit the room walking backward while wearing an apron

While changing a newborn's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern? A) Assess for other signs of bleeding B) Obtain an order for vaginal cultures C) Explain that this is an expected finding D) Apply a urine specimen bag to the perineum

C) Explain that this is an expected finding

Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A) Direct the client to sign a liability release form. B) Restrict the client's ability to leave the unit. C) Explain the benefits of remaining in the hospital. D) Instruct the client to take medications as prescribed. E) Provide the client with names of local support groups. F) Notify the health care provider of the client's intention.

C) Explain the benefits of remaining in the hospital. D) Instruct the client to take medications as prescribed. F) Notify the health care provider of the client's intention. - Correct responses are (C, D, and F). To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

What clinical indicator is important for the nurse to assess after a client undergoes a submucosal resection for a deviated septum? A) Occipital headache B) Periorbital edema C) Exportation of blood D) Changes in vocalization

C) Exportation of blood

A nurse provides dietary teaching about a low-sodium diet for a client with HTN. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium? A) Milk B) Meat C) Fruits D) Vegetables

C) Fruits

A nurse is evaluating a client who has been receiving medical intervention for the diagnosis of Crohn disease. What expected outcome is most important for this client? A) Does skin care B) Takes oral fluids C) Gains a half pound per week D) Experiences less abdominal cramping

C) Gains a half pound per week

The nurse is preparing to administer the disease-modifying antirheumatic drug (DMARD) methotrexate (Rheumatrex) to a client diagnosed with rheumatoid arthritis. Which intervention is most important to implement prior to administering this medication? A) Assess the client's liver function test results. B) Monitor the client's intake and output. C) Have another nurse check the prescription. D) Assess the client's oral mucosa.

C) Have another nurse check the prescription. - Double-checking the prescription (C) is an important intervention because death can occur from an overdose. This medication is administered weekly and in low doses for rheumatoid arthritis and should not be confused with administration of the drug as a chemotherapeutic agent. (A and B) are appropriate interventions for those who are receiving this drug, but they are not the most important interventions. Stomatitis (D) is an expected side effect of this medication.

A medication that is classified as a beta-1 agonist is most commonly prescribed for a client with which condition? A) Glaucoma. B) Hypertension. C) Heart failure. D) Asthma.

C) Heart failure. - Beta-1 agonists improve cardiac output by increasing the heart rate and blood pressure and are indicated in heart failure (C), shock, atrioventricular block dysrhythmias, and cardiac arrest. Glaucoma (A) is managed using adrenergic agents and beta-adrenergic blocking agents. Beta-1 blocking agents are used in the management of hypertension (B). Medications that stimulate beta-2 receptors in the bronchi are effective for bronchoconstriction in respiratory disorders, such as asthma (D).

A thin older adult client is diagnosed with osteoporosis. What should the nurse include in the discharge plan for this client? A) Encouragement of gradual weight gain B) Monitoring for decreased urine calcium C) Instructions relative to diet and exercise D) Safety factors when using opioids and NSAIDS

C) Instructions relative to diet and exercise

The nurse is caring for a client with diabetes mellitus. What is the primary fluid shift that occurs with this condition? A) Intravascular to interstitial because of glycosuria B) Interstitial to extracellular because of hypoproteinemia C) Intracellular to intravascular because of hyperosmolarity D) Intercellular to intravascular because of increased hydrostatic pressure

C) Intracellular to intravascular because of hyperosmolarity - The osmotic effect of hyperglycemia pulls fluid from the intracellular and interstitial compartments, resulting in dehydration. Hyperglycemia pulls fluid from the interstitial to the intravascular compartment, eventually spilling into the urine. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds other osmotic forces. An increase in hydrostatic pressure results in an intravascular to interstitial shift.

Why is it important for a nurse to support the parents' decision to abort a fetus with a birth defect even if the nurse is morally against abortion? A) Supporting them will eliminate feelings of guilt B) The parents are legally responsible for the decision C) It is essential for maintenance of the family equilibrium D) The nurse's support will relieve the pressure caused by this decision

C) It is essential for maintenance of the family equilibrium

A client has a urinary retention catheter in place after surgery. What should the nurse do when planning the client's safety needs in relation to this device? A) Empty the bag every 6 hour s B) Maintain the tension on the tubing C) Keep the system closed at all times D) Attach the bag to the side rail of the bed

C) Keep the system closed at all times - Urinary catheter systems should be kept closed at all times. The bag should be emptied more frequently than every 6 hours. Tension should be relieved not maintained. The bag should not be attached to the side rail of the bed because if the side rail is moved the catheter may detach.

A client has severe diarrhea, and the HCP prescribes IV fluids, sodium bicarbonate, and an antidiarrheal medication. Which most frequently ordered antidiarrheal drug does the nurse expect the HCP to prescribe? A) Bisacodyl B) Psyllium C) Loperamide D) Docusate sodium

C) Loperamide

An antacid (Maalox) is prescribed for a client with peptic ulcer disease. The nurse knows that the purpose of this medication is to: A) Decrease production of gastric secretions. B) Produce an adherent barrier over the ulcer. C) Maintain a gastric pH of 3.5 or above. D) Decrease gastric motor activity.

C) Maintain a gastric pH of 3.5 or above. - The objective of antacids is to neutralize gastric acids and keep pH of 3.5 or above (C) which is necessary for pepsinogen inactivity. (A) is the purpose of H2 receptor antagonists (cimetidine, ranitidine). (B) is the purpose of sucralfate (Carafate). (D) is the purpose of anticholinergic drugs which are often used in conjunction with antacids to allow the antacid to remain in the stomach longer.

A nurse is caring for a client after radioactive iodine is administered for Graves disease. What information about the client's condition after this therapy should the nurse consider when providing care? A) Not radioactive and can be handled as any other individual B) Highly radioactive and should be isolated as much as possible C) Mildly radioactive but should be treated with routine safety precautions D) Not radioactive but may still transmit some dangerous radiations and must be treated with precautions.

C) Mildly radioactive but should be treated with routine safety precautions

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation on the operative site. For which most critical reaction should the nurse assess the client? A) Dry skin B) Skin reactions C) Mucosal edema D) Bone marrow suppression

C) Mucosal edema - Mucosal edema can lead to airway obstruction, therefore it is the most critical reaction to assess for.

The health care provider prescribes carbamazepine (Tegretol) for a child whose tonic-clonic seizures have been poorly controlled. The nurse informs the mother that the child must have blood tests every week. The mother asks why so many blood tests are necessary. Which complication is assessed through frequent laboratory testing that the nurse should explain to this mother? A) Nephrotoxicity B) Ototoxicity C) Myelosuppression D) Hepatotoxicity

C) Myelosuppression - Myelosuppression (C) is the highest priority complication that can potentially affect clients managed with carbamazepine (Tegretol) therapy. The client requires close monitoring for this condition by weekly laboratory testing. Hepatic function may be altered (D), but this complication does not have as great a potential for occurrence as (C). (A and B) are not typical complications of carbamazepine (Tegretol) therapy.

A client with metastatic cancer who has been receiving fentanyl (Duragesic) for several weeks reports to the nurse that the medication is not effectively controlling the pain. Which intervention should the nurse initiate? A) Instruct the client about the indications of opioid dependence. B) Monitor the client for symptoms of opioid withdrawal. C) Notify the health care provider of the need to increase the dose. D) Administer naloxone (Narcan) per PRN protocol for reversal.

C) Notify the health care provider of the need to increase the dose. - Clients can develop a tolerance to the analgesic effect of opioids and may require an increased dose (C) for effective long-term pain relief. The client is not exhibiting indications of dependence (A), withdrawal (B), or toxicity (D).

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the initial nursing action? A) Use techniques to distract the client B) Include the client in decision making C) Offer to spend more time with the client D) Help the client to problem-solve personal issues

C) Offer to spend more time with the client

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A) Inspection of the skin B) Breath sound auscultation C) Pain scale measurement D) Mobility limitations

C) Pain scale measurement - Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority (C). (A, B, and D) are part of the complete assessment but do not have the priority of (C) for this client.

A client has myxedema, which results from a deficiency of thyroid hormone synthesis in adults. The nurse knows that which medication should be contraindicated for this client? A) Liothyronine (Cytomel) to replace iodine. B) Furosemide (Lasix) for relief of fluid retention. C) Pentobarbital sodium (Nembutal Sodium) for sleep. D) Nitroglycerin (Nitrostat) for angina pain.

C) Pentobarbital sodium (Nembutal Sodium) for sleep. - Persons with myxedema are dangerously hypersensitive to narcotics, barbiturates (C), and anesthetics. They do tolerate liothyronine (Cytomel) (A) and usually receive iodine replacement therapy. These clients are also susceptible to heart problems such as angina for which nitroglycerin (Nitrostat) (D) would be indicated, and congestive heart failure for which furosemide (Lasix) (B) would be indicated.

Which food selected by a client with osteoporosis indicates that the nurse's dietary teaching was effective? A) Red meat B) Soft drinks C) Turnip greens D) Enriched grains

C) Turnip greens - Turnip greens are high in calcium.

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? A) Food planning and selection. Incorrect B) Administering insulin injections. C) Process of glucose testing. D) Drawing up the correct insulin dose.

C) Process of glucose testing. - Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors.

A client with a history of gambling has legal difficulties for embezzling money and is required to obtain counseling. During an intake interview, the client says, "I never would have done this if I had been paid what I am worth." What factor will create the greatest difficulty when assisting this client to develop insight? A) Feelings of boredom and emptiness B) Grandiosity related to personal abilities C) Projection of reasons for difficulties onto others D) Anger toward those who are in authority positions

C) Projection of reasons for difficulties onto others

Which hormones are secreted by the client's hypothalamus? Select all that apply. A) Growth hormone B) Follicle-stimulating hormone C) Prolactin-inhibiting hormone D) Corticotropin-releasing hormone E) Melanocyte-stimulating hormone

C) Prolactin-inhibiting hormone D) Corticotropin-releasing hormone - The hormones that are secreted by the hypothalamus include prolactin-inhibiting hormone and corticotropin-releasing hormone. Growth hormone, follicle-stimulating hormone, and melanocyte-stimulating hormone are hormones secreted by the anterior pituitary gland.

A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? Select all that apply. A) Insomnia B) Ecchymoses C) Rectal pressure D) Abdominal pain E) Skipped periods F) Pelvic infections

C) Rectal pressure D) Abdominal pain

A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include the teaching when explaining how diuretics reduce blood pressure? A) Facilitates vasodilation B) Promotes smooth muscle relaxation C) Reduces the circulating blood volume D) Blocks the sympathetic nervous system

C) Reduces the circulating blood volume

A client who is HIV-positive is receiving combination therapy with the antiviral medication zidovudine (Retrovir). Which instruction should the nurse include in this client's teaching plan? A) Take the drug as prescribed to cure HIV infections. B) Use the drug to reduce the risk of transmitting HIV to sexual contacts. C) Return to the clinic every 2 weeks for blood counts. D) Report to the health care provider immediately if dizziness is experienced.

C) Return to the clinic every 2 weeks for blood counts. - Bone marrow depression with granulocytopenia is a severe but common adverse effect of zidovudine (Retrovir). Careful monitoring of CBCs is indicated (C). (A and B) are not correct instructions related to use of this medication. (D) is an expected side effect. The client should be instructed to avoid driving until this reaction improves.

Which nursing diagnosis is important to include in the plan of care for a client receiving the angiotensin-2 receptor antagonist irbesartan (Avapro)? A) Fluid volume deficit. B) Risk for infection. C) Risk for injury. D) Impaired sleep patterns.

C) Risk for injury. - Avapro is an antihypertensive agent, which acts by blocking vasoconstrictor effects at various receptor sites. This can cause hypotension and dizziness, placing the client at high risk for injury (C). Avapro does not act as a diuretic (A), impact the immune system (B), or alter sleep patterns (D).

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A) Participating in telephone consultations with clients B) Identifying oneself by name and title to clients in telehealth communications C) Sending medical records to health care providers via the Internet D) Answering a client-initiated health question via electronic mail

C) Sending medical records to health care providers via the Internet - Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred (C). Client confidentiality is protected by federal wiretapping laws making telephone consultation (A) a private and protected form of communication. By stating one's name and credentials in telehealth communication (B), one is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk than sending records via the Internet.

A preschool-age child has been restricted to bed rest since admission to the hospital. As a response to the improvement, the child becomes interested in playing. Based on the child's developmental level and activity restriction, what should the nurse provide? A) Television viewing time B) Squeaky stuffed animals C) Small farm animals and a little barn D) Simple three-or four-piece wooden puzzles

C) Small farm animals and a little barn

What gross motor skills should the nurse expect a developmentally appropriate 3-year-old child to perform? Select all that apply. A) Skipping on alternate feet B) Riding alone on a small bicycle C) Standing on one foot for a few seconds D) Alternating feet when walking up the stairs E) Jumping rope by lifting both feet simultaneously

C) Standing on one foot for a few seconds D) Alternating feet when walking up the stairs

A client who is receiving chlorpromazine HCl (Thorazine) to control his psychotic behavior also has a prescription for benztropine (Cogentin). When teaching the client and/or significant others about these medications, what should the nurse explain about the use of benztropine (Cogentin) in the treatment plan for this client? A) This medication will reduce the side effect of urinary retention. B) This drug potentiates the effect of chlorpromazine HCl (Thorazine). C) The benztropine (Cogentin) is used to control extrapyramidal symptoms. D) The combined effect of these drugs will modify psychotic behavior.

C) The benztropine (Cogentin) is used to control extrapyramidal symptoms. - Benztropine (Cogentin), an anticholinergic drug, is used to control extrapyramidal symptoms (C) associated with chlorpromazine HCl (Thorazine) use. (A, B, and D) are not accurate statements regarding the use of benztropine (Cogentin) for clients who are treated with Thorazine for the control of psychosis.

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A) Adjustment of orthodontic appliances or braces B) Loss of deciduous teeth (baby teeth) C) Urinary catherization D) Insect bites

C) Urinary catherization - Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization (C) is an invasive procedure. (A, B, and D) are not invasive and do not require administration of prophylactic antibiotics.

A nurse is caring for a client after surgical creation of a conduit diversion. What is the major disadvantage of a conduit diversion that the nurse should consider when caring for this client? A) Peristalsis is greatly decreased B) Stool continuously oozes from it C) Urine continuously drains from it D) Absorption of nutrients is diminished

C) Urine continuously drains from it

Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? A) Urine output B) Specific gravity C) Urine osmolarity D) Serum osmolarity

C) Urine osmolarity - Polydipsia and polyuria are signs of diabetes insipidus. When a water deprivation test is performed, urine osmolarity is increased dramatically from 100 to 600 mOsm (mmol)/kg in clients with central diabetes insipidus. But in nephrogenic diabetes insipidus, the urine osmolarity may not be greater than 300 mOsm (mmol)/kg. The urine output is 2 L to 20 L/day in all types of diabetes insipidus. The specific gravity is less than 1.005 in all types of diabetes insipidus and the serum osmolarity is also greater than 295 mOsm (mmol)/kg in all types of diabetes insipidus.

During a prenatal visit, a client at 36 weeks' gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend? A) Lie down until they stop B) Time them for at least 1 hour C) Walk around until they subside D) Take 1 over-the-counter analgesic

C) Walk around until they subside - Walking around until the contractions subside will differentiate true from false labor.

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A) Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B) Apply ice packs to edematous or tender joints to reduce pain and swelling. C) Warm the child with an electric blanket prior to getting the child out of bed. D) Immobilize swollen joints during acute exacerbations until function returns.

C) Warm the child with an electric blanket prior to getting the child out of bed. - Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. (A) on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness (B). (D) is contraindicated, because joints should be exercised, not immobilized.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A) Remove all blackheads and follow with an alcohol scrub. B) Use medicated cosmetics only to help hide the blemishes. C) Wash the hair and skin frequently with soap and hot water. D) Encourage her to see a dermatologist as soon as possible.

C) Wash the hair and skin frequently with soap and hot water. - Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful.

9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

Check the client for lacerations or fractures

404. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?

Chest discomfort one hour after consuming a large, spicy meal

Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A.Direct the client to sign a liability release form. B.Restrict the client's ability to leave the unit. C.Explain the benefits of remaining in the hospital. D.Instruct the client to take medications as prescribed. E.Provide the client with names of local support groups. F.Notify the health care provider of the client's intention.

CDF Correct responses are (C, D, and F). To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

276. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?

CPT should be performed more frequently, but at least an hour before meals.

574. Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?

Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

Capillary refill of 8 seconds

1. Myocardial automaticity-patho

Cardiac dysrhythmias associated with altered myocardial automaticity, conductivity or contractility can effect cardiac output. Reduced cardiac output increases the risk of ineffective tissue perfusion.

During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women?

Chlamydia. Chlamydia (B) is the most common and fastest spreading sexually transmitted infection (STI) in American women, with an estimated 3 million new cases each year

224. The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

393. A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide?

Cinnamon applesauce

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client requests an afternoon snack, which dietary choice should the nurse provide?

Cinnamon applesauce

505. The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take?

Clamp the tubing and instruct the client to breathe deeply before continuing.

88. The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Clear fluid leaking from the nose.

169. When evaluating a client's rectal bleeding, which findings should the nurse document?

Color characteristics of each stool.

116. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply

Contains a list with definitions of unfamiliar terms Uses common words with few Syllables Uses pictures to help illustrate complex ideas

552. A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy...Which action should the nurse instruct the parents to take if the child begins to vomit?

Continue giving ORS frequently in small amounts

A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy... Which action should the nurse instruct the parents to take if the child begins to vomit?

Continue giving ORS frequently in small amounts

The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing

Continue to monitor the client to see if the bubbling increases

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital physician that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember?

Correct : That a DNR order may be written by a client's physician

96. The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?

Reposition the restraint tie onto the bedframe.

614. In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

Serum creatinine

What is the nursing action for dehiscence:

Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's .

An older adult client who has a duodenal ulcer has been taking cimetidine for the past 2 weeks to monitor for cimetidine toxicity which lab studies should the nurse monitor? SATA

Creatine Clearance and Liver function test (LFT) panel

322. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse?

Creatinine 4 mg/dl (354 micromol/L SI)

25. The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? a) Stares straight ahead without blinking b) Face does not convey any emotion c) Uses a monotone when speaking d) Cries frequently during the interview

Cries frequently during the interview

484. The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs?

Cries frequently during the interview

140. A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?

Crutches with 4 point gait.

390. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Culture for sensitive organisms.

326. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Current diagnosis of hepatitis B.

496. A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client's hand, which finding required most immediate follow-up by the nurse?

Cyanotic nailbeds

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A.Ask the client to describe the symptoms of the vaginal infection. B.Assess if the client has been sexually active recently. C.Tell the client to reschedule the examination in 1 week. D.Inform the client that the scheduled Pap test cannot be done today.

D The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed (D). Although (A, B, and C) are indicated, the client needs further teaching for the return visit to perform the Pap smear test.

A client with type 2 diabetes, who is taking an oral hypoglycemic agent, is to have a serum glucose test early in the morning. The client asks the nurse, "What do I have to do to prepare for this test?" Which statement by the nurse reflects accurate information? A) "Eat your usual breakfast." B) "Have clear liquids for breakfast." C) "Take your medication before the test." D) "Do not ingest anything before the test."

D) "Do not ingest anything before the test." - Fasting before the test is indicated for accurate and reliable results; food before the test will increase serum glucose levels through metabolism of the nutrients. Food should not be ingested before the test; food will increase the serum glucose level, negating accuracy of the test. Instructing the client to have clear liquids for breakfast is inappropriate; some clear fluids contain simple carbohydrates, which will increase the serum glucose level. Medications are withheld before the test because of their influence on the serum glucose level.

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A) "Have you ever been told that you have hardening of the arteries?" B) "Do you frequently experience eye pain?" C) "Do you have high blood pressure or kidney problems?" D) "Does anyone in your family have glaucoma?"

D) "Does anyone in your family have glaucoma?" - Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member (D). (A and C) are not related to glaucoma. Glaucoma rarely causes pain (B), which is why screening is so important.

A client is taking famotidine (Pepcid). Which client statement should the nurse further assess because it may indicate that the client is experiencing a side effect of this drug? A) "I have heartburn whenever I lie down." B) "I am never hungry. I've lost weight in the past 2 weeks." C) "I have a funny metallic taste in my mouth." D) "I seem to be having difficulty thinking clearly."

D) "I seem to be having difficulty thinking clearly." - A common side effect of Pepcid is confusion (D). (A, B, and C) are not side effects of this medication.

When teaching a class about parenting, the nurse asks the participants what they do when their toddlers have a temper tantrum. Which statement demonstrates one parent's understanding of the origin of temper tantrums? A) "After a temper tantrum, I discipline my child by restricting a favorite food or candy." B) "When a temper tantrum begins, I isolate and ignore my child until the behavior improves." C) "During a temper tantrums, I partially give in to my child before the tantrum becomes excessive." D) "I try to prevent a temper tantrum by allowing my child to chose between two reasonable alternatives."

D) "I try to prevent a temper tantrum by allowing my child to chose between two reasonable alternatives."

The nurse is evaluating a client's understanding of the prescribed antilipemic drug lovastatin (Mevacor). Which client statement indicates that further teaching is needed? A) "My bowel habits should not be affected by this drug." B) "This medication should be taken once a day only." C) "I will still need to follow a low-cholesterol diet." D) "I will take the medication every day before breakfast."

D) "I will take the medication every day before breakfast." - The enzyme that helps metabolize cholesterol is activated at night, so this medication should be taken with the evening meal (D). (A, B, and C) reflect correct information about lovastatin.

A client is diagnosed with uterine fibroids, and the HCP advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's most appropriate response? A) "You are correct, but there are medicines you can take that will ease the symptoms." B) "This sometimes occurs in women of your age, but you needn't worry about it at this time." C) "Perhaps you should talk to your surgeon because I am not allowed to discuss this with you." D) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."

D) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."

A 15-year-old sexually active girl diagnosed with pelvic inflammatory disease (PID) is admitted to the hospital with a temperature of 101.6° F and a purulent vaginal discharge. She has no insurance and tells the nurse she enjoys small children. Which room should the nurse assign this client? A) A semi-private room with a 4-year-old girl who is currently receiving chemotherapy. B) A semi-private room with an older adolescent girl who had surgery yesterday. Incorrect C) A room close to the nurse's station. D) A private room.

D) A private room. - Despite the fact that the client has no insurance and enjoys small children, she is infected and should be placed in a private room (D). This client is infected, which is a priority consideration, so (A and B) would not be the best room assignment for this client because they would put the roommates at serious, unnecessary risk. This client is not acutely ill and does not need to be assigned to a room next to the nurse's station (C).

The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystis carinii pneumonia, secondary to acquired immunodeficiency syndrome (AIDS). Which room would be best to assign to this client? A) A private room fully equipped with an outside air ventilation system. B) A semi-private room shared with an bed-ridden elder who would enjoy the company. C) A semi-private room with a bed available nearest to the bathroom. D) A semi-private room that does not have a client in the other bed at this time.

D) A semi-private room that does not have a client in the other bed at this time. - A semi-private room without a roommate (D) is the best assignment because the room can be easily blocked to create a private room should the client require isolation measures due to the pneumonia (the AIDS diagnosis alone does not affect the type of room assignment). A client with pneumonia should not be exposed to an outside air ventilation system (A). The client should not be assigned to a room with a client who is at risk for pneumonia (B). Mobility is not a factor for this client, therefore (C) is not indicated.

What clinical finding indicates to the nurse that the client may have hypokalemia? A) Edema B) Muscle spasms C) Kussmaul breathing D) Abdominal distension

D) Abdominal distension

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? A) Anger B) Denial C) Depression D) Acceptance

D) Acceptance - In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

The nurse is preparing to administer a secondary infusion of a dobutamine solution to a client. The nurse notes that the solution is brown in color. Which action should the nurse implement? A) Verify the prescribed dose with the health care provider. B) Discard the solution and reorder from the pharmacy. C) Dilute the solution with more normal saline until it becomes lighter in color. D) Administer the drug if the solution's reconstitution time is less than 24 hours.

D) Administer the drug if the solution's reconstitution time is less than 24 hours. - The color of the dobutamine solution is normal (D), and it should administered within 24 hours after reconstitution, so the time of reconstitution should be verified before administering the solution of medication. (A) is not indicated. (B) is not necessary. Additional dilution of a drug in solution is stated in the manufacturer's reconstitution instructions, but (C) is not needed.

A nurse is teaching a group of women about the side effects of different types of contraceptives. What is the most frequent side effect associated with the use of an intrauterine device (IUD)? A) A tubal pregnancy B) A rupture of the uterus C) An expulsion of the device D) An excessive menstrual flow

D) An excessive menstrual flow

A client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior? A) Hyperkalemia B) Hypernatremia C) A limited fluid intake D) An increased BUN

D) An increased BUN

A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care? A) Turn the client every 4 hours. B) Restrict dietary protein intake. C) Perform passive range of motion 4 times per day. D) Apply a pressure-relieving mattress under the client.

D) Apply a pressure-relieving mattress under the client. - The client's risk for impaired skin integrity requires meticulous skin care because the edematous tissues are showing indications of breakdown. A pressure-relieving mattress (D) should be used to reduce the risk of skin tearing with manual turning. Although (A and C) are valuable in preventing complications of immobility, the client's skin integrity is threatened by fluid retention and requires measures to prevent breakdown. Dietary protein (B) may be indicated with hepatic encephalopathy, but the client's skin integrity is threatened by pitting edema and ascites and should be addressed.

A nurse in the surgical ICU is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? A) Vitamin A B) Cyanocobalamin C) Phytonadione D) Ascorbic Acid

D) Ascorbic Acid - Ascorbic Acid is also known as Vitamin C and aids in collagen production.

A mother brings her 18-month-old child to the community health center because the child has had "bad diarrhea" for the last 3 days. She states, "I bought some of this liquid at the pharmacy and gave my daughter a half-ounce." The nurse sees that the bottle contains loperamide (Imodium AD). Which intervention is most important for the nurse to implement initially? A) Tell the mother never to give this drug to her toddler. B) Ask if any other siblings have experienced diarrhea. C) Take the child's oral and tympanic temperatures. D) Ask the mother when the child last voided.

D) Ask the mother when the child last voided. - Determining when the child last voided (D) is most important because urine output is decreased with dehydration and an 18-month-old with a 3-day history of diarrhea could be severely dehydrated. Although the manufacturer states that loperamide (Imodium AD) should not be given to a child younger than 2 years except under the direction of a health care provider (A), this information is not the best answer for this question. In addition, loperamide (Imodium AD) causes an anticholinergic effect of urinary retention. Data obtained in (B and C) are not as high a priority as (D) in this situation.

The health care provider prescribes ipratropium (Atrovent) for a client. An allergic reaction to which other medication would cause the nurse to question the prescription for Atrovent? A) Albuterol (Proventil) B) Theophylline (Theo-24) C) Metaproterenol (Alupent) D) Atropine sulfate (Atropine)

D) Atropine sulfate (Atropine) - Clients who have experienced allergic reactions to atropine sulfate (Atropine) (D) and belladonna alkaloids may also be allergic to ipratropium (Atrovent), so the prescription for Atrovent should be questioned. Allergies to (A, B, and C) would not cause the nurse to question a prescription for ipratropium (Atrovent).

A HCP prescribes tolterodine for a client with an overactive bladder. What is most important for the nurse to teach the client to do? A) Maintain a strict record of fluid intake and urinary output B) Chew the extended release capsule thoroughly before swallowing C) Report episodes of diarrhea or any increase in respiratory secretions D) Avoid activities requiring alertness until the response to the medication is known

D) Avoid activities requiring alertness until the response to the medication is known - Tolterodine is a urinary antispasmodic and may cause dizziness.

Using Piaget's theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate? A) Early traces of memory B) Beginning sense of time C) Repetitious reflex responses D) Beginning of object permanence

D) Beginning of object permanence

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A) Ask the UAP to check for the advanced directive while the nurse completes the assessment. B) Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C) Check the medical record for the advanced directive and then complete the client assessment. D) Call for the charge nurse to check the advanced directive while continuing to assess the client.

D) Call for the charge nurse to check the advanced directive while continuing to assess the client. - Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all of the cholesterol in my body so it isn't a problem? Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? A) Blood clotting B) Bone formation C) Muscle contraction D) Cellular metabolism

D) Cellular metabolism

Which nursing action can best prevent infection from a urinary retention catheter? A) Cleansing the perineum B) Encouraging adequate fluids C) Irrigating the catheter once daily D) Cleansing around the meatus routinely

D) Cleansing around the meatus routinely

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A) Invite other children home to share meals. B) Accept that he will eat when he is hungry. C) Reward the child with a nap after eating. D) Consistently follow a set mealtime routine.

D) Consistently follow a set mealtime routine. - A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.

A client who has trouble swallowing pills intermittently has been prescribed venlafaxine (Effexor XR) for depression. The medication comes in capsule form. What should the nurse include in the discharge teaching plan for this client? A) Capsule contents can be sprinkled on pudding or applesauce. B) Chew the medication thoroughly to enhance absorption. C) Take the medication with a large glass of water or juice. D) Contact the health care provider for another form of medication.

D) Contact the health care provider for another form of medication. - Venlafaxine (Effexor XR) is administered PO in capsule form. Capsules that are extended-release (XR) or continuous-release (CR) contain delayed-release, enteric-coated granules to prevent decomposition of the drug in the acidic pH of the stomach. The client should notify the health care provider about the inability to swallow the capsule (D). This medication should not be chewed or opened so that the delayed-release, enteric-coated granules can remain intact (A and B). Water or juice (C) will not affect the medication.

The health care provider has prescribed a low-molecular-weight heparin, enoxaparin (Lovenox) prefilled syringe, 30 mg/0.3 mL IV every 12 hours, for a client following hip replacement. Prior to administering the first dose, which intervention is most important for the nurse to implement? A) Assess the client's IV site for signs of inflammation. B) Evaluate the client's degree of mobility. C) Instruct the client regarding medication side effects. D) Contact the health care provider to clarify the prescription.

D) Contact the health care provider to clarify the prescription. - Lovenox is a low-molecular-weight heparin that can only be administered subcutaneously, so the nurse should contact the health care provider to clarify the route of administration (D). (A and B) are important nursing interventions but not necessary to the administration of this medication. The client should be instructed about medication side effects (C), but this is of lower priority than obtaining a correct prescription.

A client who had an organ transplant is receiving cyclosporine. For what should the nurse monitor to identify a serious adverse effect of cyclosporine? A) Skin for hirsutism B) Stools for constipation C) Heart rhythm for dysrhythmias D) Creatinine level for an increase

D) Creatinine level for an increase - Cyclosporine causes nephrotoxicity.

When developing a written nursing care plan for a client receiving chemotherapy for treatment of cancer, the nurse writes, "Assess each voiding for hematuria." The administration of which type of chemotherapeutic agent would prompt the nurse to add this intervention? A) Vincristine B) Bleomycin sulfate C) Chlorambumacil D) Cyclophosphamide

D) Cyclophosphamide Hemorrhagic cystitis is the characteristic adverse reaction of cyclophosphamide (Cytoxan) (D). Administration of (A, B, and C) does not typically cause hemorrhagic cystitis.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A) The occurrence of any episodes of sleep apnea B) The child's blood pressure, pulse, and respirations C) Length of rapid eye movement (REM) sleep that the child is experiencing D) Description of the family's home environment

D) Description of the family's home environment - School-age children often resist bedtime. The nurse should begin by assessing the environment of the home (D) to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. (A) often causes daytime fatigue rather than resistance to going to sleep. (B) is unlikely to provide useful data. The nurse cannot determine (C).

During the first prenatal visit of a woman who is at 23 weeks' gestation, the nurse discovers that the client has a history of pica. What is the most appropriate nursing action? A) Seek a physiologic referral B) Explain the danger this poses to the fetus C) Obtain a prescription for an iron supplement D) Determine whether the diet is nutritionally adequate

D) Determine whether the diet is nutritionally adequate - Patients who have a history of pica typically have a nutritionally INADEQUATE diet, so the nurse should assess the patient's regular diet.

A female client with myasthenia gravis is taking a cholinesterase inhibitor and asks the nurse what can be done to remedy her fatigue and difficulty swallowing. What action should the nurse implement? A) Explore a plan for development of coping strategies for the symptoms with the client. B) Explain to the client that the dosage is too high, so she should skip every other dose of medication. C) Advise the client to contact her health care provider because of the development of tolerance to the medication. D) Develop a teaching plan for the client to self-adjust the dose of medication in response to symptoms.

D) Develop a teaching plan for the client to self-adjust the dose of medication in response to symptoms. - Maintaining optimal dosage for cholinesterase inhibitors can be challenging for clients with myasthenia gravis. Clients should be taught to recognize signs of overmedication and undermedication so that they can modify the dosage themselves (D) based on a prescribed sliding scale. (A, B, and C) do not adequately address the client's concerns.

A client has a transverse loop colostomy. What should the nurse do when inserting a catheter for the colostomy irrigation? A) Use an oil-based lubricant B) Instruct the client to gently bear down C) Apply gentle but continuous pressure D) Direct it toward the client's right side

D) Direct it toward the client's right side

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A) Use the normal saline solution once more and then discard. B) Obtain a new sterile syringe to draw up the labeled saline solution. C) Use the saline solution and then relabel the bottle with the current date. D) Discard the saline solution and obtain a new unopened bottle.

D) Discard the saline solution and obtain a new unopened bottle. - Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded (D). (A, B, and C) describe incorrect procedures.

An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A) Take the client's blood pressure and reassure her that the questioning will not cause a heart attack B) Explain that treatment is based on the information obtained in the assessment C) Encourage the client to relax so that she can provide the information requested D) Empower the client to share her story of why she is here at the mental health clinic

D) Empower the client to share her story of why she is here at the mental health clinic - The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety.

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A) Airway obstruction B) Inadequate nutrition C) Prolonged gastric suction D) Excessive mechanical ventilation

D) Excessive mechanical ventilation - The patient is exhibiting symptoms of respiratory alkalosis, which is commonly caused by mechanical ventilation.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. What action should the nurse take? A) Institute the ordered blood transfusion because the client's surgical depends on volume replacement B) Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion C) Phone the HCP for an administrative order to give the transfusion under these circumstances D) Give the spouse a treatment refusal form to sign and notify the HCP that a court order can now be sought

D) Give the spouse a treatment refusal form to sign and notify the HCP that a court order can now be sought - The client is unconcious. Although the spouse can give consent, there is no legal power to refuse treatment for the client unless previously authorized to do so by the power of attorney or a health care proxy ; the court can make a decision for the client.

A nurse is transferring a client with a diagnosis of pheochromocytoma from a bed to a chair. What is the MOST important nursing intervention associated with this procedure for this client? A) Supporting the client on the weak side B) Ensuring that the chair is close to the client's bed C) Placing sturdy shoes with rubber soles on the client's feet D) Having the client sit on the side of the bed for a few minutes before the transfer

D) Having the client sit on the side of the bed for a few minutes before the transfer - Having the client sit on the side of the bed for several minutes allows time for the blood pressure to adjust to the vertical position; this avoids dizziness and the potential for fainting or falling.

Dobutamine (Dobutrex) is an emergency drug most commonly prescribed for a client with which condition? A) Shock. B) Asthma. C) Hypotension. D) Heart failure.

D) Heart failure. - Dobutamine is a beta-1 adrenergic agonist that is indicated for short term use in cardiac decompensation or heart failure (D) related to reduced cardiac contractility due to organic heart disease or cardiac surgical procedures. Alpha and beta adrenergic agonists, such as epinephrine and dopamine, are sympathomimetics used in the treatment of shock (A). Other selective beta-2 adrenergic agonists, such as terbutaline and isoproterenol, are indicated in the treatment of asthma (B). Although dobutamine improves cardiac output, it is not used to treat hypotension (C).

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. What response should the nurse assess this client for? A) Hypovolemia B) Hyperkalemia C) Hypoglycemia D) Hypernatremia

D) Hypernatremia - A client with Cushing syndrome secretes excess amounts of cortisol, a corticosteroid that acts to retain sodium and water, resulting in hypernatremia and edema. Hypervolemia, not hypovolemia, is caused by fluid retention. Hypokalemia, not hyperkalemia, occurs because potassium is lost when there is sodium retention. Hyperglycemia, not hypoglycemia, results from cortisol-induced glucose intolerance.

A nurse is caring for a client who had a hypophysectomy. For which complications specific to this surgery should the nurse assess the client for early clinical manifestations? A) Urinary retention B) Respiratory distress C) Bleeding at the suture line D) Increased ICP

D) Increased ICP - Because the pituitary gland is located in the brain, edema after surgery may result in increased ICP. Early signs include decreased visual acuity, papilledema, and unilateral pupillary dilatation.

A HCP prescribes simvastatin 20 mg daily for elevated cholesterol and triglyceride levels for a middle-age female. Which is most important for the nurse to teach the client to do when initially taking this medication? A) Take the medication with breakfast B) Have liver function tests twice a year C) Wear sunscreen to prevent photosensitivity reactions D) Inform the HCP if becoming pregnant is desired

D) Inform the HCP if becoming pregnant is desired - Simvastatin use is contraindicated during pregnancy.

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis? A) Limit the client's daily fat intake to 30%. B) Increase the client's fluid intake to 3000 ml daily. C) Place pillows under the client when lying supine. D) Initiate a smoking cessation program.

D) Initiate a smoking cessation program. - As the spine progressively stiffens, the client with ankylosing spondylitis should be encouraged to stop smoking (D) to decrease the risk for pulmonary complications related to reduced chest expansion and movement. Although recommended health promotion practices (A and B) should be encouraged, the risk of complications with ankylosing spondylitis is increased if the client continues to smoke. Using pillows under the client when lying supine may promote comfort, but should be evaluated to prevent flexion that increases the client's risk for flexion or fixation deformity (D).

A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach? A) Z-track B) IV C) SQ D) Intradermal scratch

D) Intradermal scratch

What must the nurse emphasize to a family when preparing a child with persistent asthma for discharge? A) A cold, dry environment is desirable B) Limits should not be placed on the child's behavior C) The health problem is gone when symptoms subside D) Medications must be continued even when asymptomatic

D) Medications must be continued even when asymptomatic

A nurse administers the prescribed regular insulin (Novolin R) to a client in DKA. In addition, the nurse anticipates that the IV solution prescribed will contain potassium to replenish potassium ions in the extracellular fluid that are being: A) Rapidly lost from the body by copious diaphoresis present during coma B) Carried with glucose to the kidneys to be excreted in the urine in increased amounts C) Quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose D) Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose

D) Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose - Insulin stimulates cellular uptake of glucose and also stimulates the sodium/potassium pump, leading to the influx of potassium into cells. The resulting hypokalemia is offset by parenteral administration of potassium.

The nurse notes that the hemoglobin level of a client receiving darbepoetin alfa (Aranesp) has increased from 6 to 10 g/dL over the first 2 weeks of treatment. Which action should the nurse take? A) Encourage the client to continue the treatment, because it is effective. B) Advise the client that the dose will need to be increased. C) Assess the client's skin color for continued pallor or cyanosis. D) Notify the health care provider of the change in the client's laboratory values.

D) Notify the health care provider of the change in the client's laboratory values. - Although an increase in the client's hemoglobin level is desired, a rapid increase (more than 1 g/dL in a 2-week period) may lead to hypertension, so the health care provider should be notified of this excessive increase (D). (A and B) may lead to a dangerous increase in blood pressure. Because the client's anemia has improved, (D) is of greater priority than continuing to monitor for signs of anemia (C).

When planning care for a child with autism, the nurse understands that given a choice, the child with autism usually enjoys playing: A) On a jungle gym B) With a cuddly toy C) With a small yellow block D) On a playground merry-go-round

D) ON a playground merry-go-round

During the postpartum period a nurse identifies a client's rubella titer is negative. What action should the nurse plan to take? A) Check for allergies to penicillin B) Alert the staff in the newborn nursery C) Assure the client that she has active immunity D) Obtain a prescription for an immunization before discharge

D) Obtain a prescription for an immunization before discharge

A client had a mastectomy asks about ERP-positive. The nurse explains that tumors cells are evaluated for estrogen receptor protein to determine the: A) Need for supplemental oxygen B) Feasibility of breast reconstruction C) Degree of metastasis has occurred D) Potential response to hormone therapy

D) Potential response to hormone therapy

An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit? A) Initiate a program of planned interaction B) Explain the nature and routines of the unit C) Explore in depth the reasons for admission D) Provide for the continuous presence of staff members

D) Provide for the continuous presence of staff members

A nurse administers an IM injection of vitamin K to a newborn. What is the purpose of the injection? A) Maintains the intestinal flora count B) Promotes proliferation of intestinal flora C) Stimulates vitamin K production in the baby D) Provides protection until intestinal flora is established

D) Provides protection until intestinal flora is established

Which response best supports the observations that the nurse identifies in a client who is experiencing a placebo effect? A) Beneficial response or cure for disease B) Behavioral or psychotropic responses C) Malingering or drug-seeking behaviors D) Psychological response to inert medication

D) Psychological response to inert medication - The placebo effect is a response in the client that is caused by the psychological impact (D) of taking an inert drug that has no biochemical properties. A placebo effect can be therapeutic, negative, or ineffective but provides no cure or benefit (A) to the client's progress. The placebo effect may evoke behavioral changes but does not affect neurochemical psychotropic changes (B). Malingering and drug seeking (C) are behaviors that a client exhibits to obtain treatment for nonexistent disorders or obtain prescription medications.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? A) Alkalosis B) Renal failure C) Hypervolemia D) Pulmonary edema

D) Pulmonary edema

A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required? A) Irritability B) Hoarseness C) Barking cough D) Rapid respirations

D) Rapid respirations

A HCP orders intermittent NG tube feeding to supplement a client's oral nutritional intake. Which hazard associated with NG tube feeding will be reduced if the nurse administers this feeding over 60 minutes? A) Distension B) Flatulence C) Indigestion D) Regurgitation

D) Regurgitation

A mother asks the nurse to explain how using time-out to discipline her 2-year-old child is an effective method. Which rationale should the nurse provide? A) Offers positive reinforcement. B) Provides a consequence to behavior. C) Extinguishes the behavior by ignoring it. D) Removes a reinforcer that a child is receiving.

D) Removes a reinforcer that a child is receiving. - Time-out is a disciplinary approach that removes a reinforcer, such as the satisfaction or attention the child receives from a behavior or activity (D). When placed in an unstimulating and isolated place, the child becomes bored and consequently agrees to behave in order to reenter the family group. Positive reinforcement (A) uses rewards that encourages a child to behave in another specified way, which reduces the unacceptable behavior. Time-out avoids physical punishment, which is a negative reinforcement (B) that may reinforce behavior because it brings attention. Although no reasoning or scolding is given with time-out, ignoring behavior allows the child to continue the behavior until it is eventually extinguished or minimized.

A nurse is caring for a client who is cachexic. What information about the function of adipose tissue in fat metabolism is necessary to better address the needs of this client? A) Releases glucose for energy B) Regulates cholesterol production C) Uses lipoproteins for fat transport D) Stores triglycerides for energy reserves

D) Stores triglycerides for energy reserves

A client who is experiencing an acute attack of gouty arthritis is prescribed colchicine (Colcrys) USP, 1 mg PO daily. Which information is most important for the nurse to provide the client? A) Take the medication with meals. B) Limit fluid intake until the attack subsides. C) Stop the medication when the pain resolves. D) Report any vomiting to the clinic.

D) Report any vomiting to the clinic. - The client should be instructed to report signs of colchicine toxicity, such as nausea, diarrhea, vomiting (D), and/or abdominal pain, to the health care provider. Food inhibits the absorption of colchicine when ingested concurrently (A). Limited fluid intake (B) decreases the excretion of the uric acid crystals, which contributes to painful attacks. Typically, a client should remain on a daily dose of colchicine to decrease the number and severity of acute attacks, so stopping the medication after the pain resolves (C) is not indicated.

A nurse is giving discharge instructions to a client who had an aspiration abortion by suction curettage. What should the client be told? A) Avoid showering for 2 days B) Tampons may be used after 1 day C) Sexual intercourse should be delayed for 3 weeks D) Report bleeding that requires pad changes every 2 hours

D) Report bleeding that requires pad changes every 2 hours

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A) Encourage the client to use a nicotine patch. B) Reassure the client that it is almost time for another break. C) Have the client leave the unit with another staff. D) Review the schedule of outdoor breaks with the client.

D) Review the schedule of outdoor breaks with the client. - The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? A) Accept the client's crying B) Encourage unrestricted family visitors C) Explain details of the care being given D) Stay nearby without initiating conversation

D) Stay nearby without initiating conversation

A client is experiencing chronic constipation and the nurse discusses how to include more bulk in the diet. The nurse concludes that learning has occurred when the client states, "Bulk in the diet promotes defecation by: A) Irritating the bowel wall B) Stimulating the intestinal mucosa chemically C) Acting on the microorganisms in the large intestine D) Stretching intestinal smooth muscle, which causes it to contract

D) Stretching intestinal smooth muscle, which causes it to contract

A client is admitted with diarrhea, anorexia, weight loss, and abdominal cramps. What clinical manifestations of an electrolyte deficit should the nurse report immediately? Select all that apply. A) Diplopia B) Skin rash C) Leg cramps D) Tachycardia E) Muscle weakness

D) Tachycardia E) Muscle weakness

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A) Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B) Sit quietly in the client's room until the client leaves the bathroom. C) Allow the client to cry alone and leave the client in the bathroom. D) Talk to the client and attempt to find out why the client is crying.

D) Talk to the client and attempt to find out why the client is crying. - The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed (D). (A) is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully (B). Although (C) may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

The nurse expects a clinical finding of cyanosis in an infant with which condition(s)? (Select all that apply.) A) Ventircular septal defect (VSD) B) Patent ductus arteriosis (PDA) C) Coarction of the aorta D) Tetrology of Fallot E) Transposition of the great vessels

D) Tetrology of Fallot E) Transposition of the great vessels - Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). The others are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. (A, B, and C).

When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection? A) The greater trochanter and the knee. B) The acromion process and the dorsal surface of the upper arm. C) The greater trochanter and the posterior iliac spine. D) The anterosuperior iliac spine and the greater trochanter.

D) The anterosuperior iliac spine and the greater trochanter. - The heel of the hand is placed on the greater trochanter and the fingers spread to palpate the anterosuperior iliac spine, which are the landmarks used to give an injection in the ventrogluteal site (D). (A) locates the vastus lateralis, (B) locates the deltoid, and (C) locates the gluteus maximus, which is no longer recommended as an IM site.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how it provides passive immunity? A) It increases production of short-lived antibodies B) It accelerates antigen-antibody union at the hepatic sites C) The lymphatic system is stimulated to produce antibodies D) The antigen is neutralized by the antibodies it supplies

D) The antigen is neutralized by the antibodies it supplies

A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive RH-negative blood because: A) It is the same as the mother's blood B) It is neutral and will not react with the baby's blood C) The possibility of a transfusion reaction is eliminated D) The red blood cells will not be destroyed by maternal anti-Rh antibodies

D) The red blood cells will not be destroyed by maternal anti-Rh antibodies

What is important for a nurse to discuss with a client who had a vasectomy? A) Recanalization of the vas deferens is impossible B) Unprotected coitus is safe within 1 week to 10 days C) Some impotency is to be expected for several weeks D) There must be 15 ejaculations to clear the tract of sperm

D) There must be 15 ejaculations to clear the tract of sperm

The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide? A) This visual acuity result is five times worse that of a normal finding. B) This line should be seen clearly when the client wears corrective lenses. C) A client with normal vision can read at 100 feet what this client reads at 20 feet. D) This client can see at 100 feet what a client with normal vision can see at 20 feet.

D) This client can see at 100 feet what a client with normal vision can see at 20 feet. - The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100 means that this client can read at 20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are inaccurate.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A) Clamp the nasogastric tube. B) Confirm placement of the tube. C) Use a syringe to instill the medications. D) Turn off the intermittent suction device.

D) Turn off the intermittent suction device. - The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B) before instilling the medications (C). To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time (A) before reconnecting the suction.

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the HCP? A) Passage of pink-tinged sputum B) Pink drainage on the dressing C) Intake of 1750 mL in 24 hours D) Urine output of 20 - 30 ml/hr

D) Urine output of 20 - 30 ml/hr

The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care? A) Provide a high caloric diet that meets the child's mental age. B) Delay solid food introduction until the child's tongue thrust subsides. C) Maintain regular meal times to minimize frequency of constipation. D) Use a bedside cool-mist vaporizer during naps and night time.

D) Use a bedside cool-mist vaporizer during naps and night time. - A child with Trisomy 21, Down syndrome, typically has an under-developed nasal bone that compromises respiratory expansion and causes a chronic problem of inadequate drainage of nasal mucus. This persistent nasal congestion forces the child to mouth-breathe, which dries the oropharyngeal membranes and increases the susceptibility to upper respiratory tract and ear infections. Using a cool-mist vaporizer (D) moistens the nasal mucous membranes, liquefies, and drains nasal secretions to reduce this medium for infection. Caloric intake is based on the child's development, height, and weight, not mental age (A). The risk for constipation is related to a decreased muscle tone, not serving times (C). Parents may need instruction about introducing solid foods, but (B) is not indicated.

A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa (Sinemet 25/100) PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? A) Take the first dose of Sinemet today, as soon as your prescription is filled. B) Since you already took your levodopa, wait until tomorrow to take the Sinemet. C) Take both drugs for the first week, then switch to taking only the Sinemet. D) You can begin taking the Sinemet this evening, but do not take any more levodopa.

D) You can begin taking the Sinemet this evening, but do not take any more levodopa. - Carbidopa significantly reduces the need for levodopa in clients with Parkinson's disease, so the new prescription should not be started until eight hours after the previous dose of levodopa (D), but can be started the same day (B). (A and C) may result in toxicity.

The nurse expects a clinical finding of cyanosis in an infant with which condition(s)? (Select all that apply.) A.Ventricular septal defect (VSD) B.Patent ductus arteriosis (PDA) C.Coarctation of the aorta D.Tetralogy of Fallot E.Transposition of the great vessels

D,E Rationale: Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). The others are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. (A, B, and C).

Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?

Dealing with the issues which are concrete, not personalities (A) which include emotional reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not resolve the conflict when diverse opinions are expressed emotionally.

599. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

Decrease abdominal girth

220. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?

Decrease in pulse rate

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note because of these increases in glaucoma surgeries?

Decrease prevalence of glaucoma in the population

174. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?

Decrease prevalence of glaucoma in the population.

The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?

Decrease the risk of bradycardia during surgery.

208. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

385. A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Determine if the sensation feels uncomfortable.

426. A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first?

Determine the client's responsiveness and respirations

476. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take?

Delegate care of the crying client to an unlicensed assistant

213. An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?

Delirium

An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?

Delirium

358. When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?

Deltoid

Which approach should the nurse use when preparing a toddler for a procedure?

Demonstrate the procedure using a doll.

A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement?

Demonstrate the wound care procedure to the PN while the PN assists

assessment findings with bulimia nervosa?

Dental erosion Patient with bulimia often appear to have a normal weight

94. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and that she is going to take him home when he is discharged. Which action should the nurse implement next? a) Consult the ethics committee to determine how to proceed b) Determine the mother's basic skill level in providing care c) Report the incident to the local Child Protective Services d) Find a home health agency that specializes in brain injuries

Determine the mother's basic skill level in providing care

319. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next?

Determine the mother's basic skill level in providing care.

371. The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?

Discussed effective use of the stockings with the client on UAP

A patient with bulimia nervosa uses ememas and laxtives to purge..,. which imbalance should the nurse assess?

Disrupted fluid and electrolyte balance

73. A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication?

Divalproex.

292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?

Divide the medication into two injection with volumes under 1ml

567. A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?

Do not get pregnant for at least 3 months

7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement?

Document the assessment data

601. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Document the finding in the infant's record.

111. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Document the ongoing wound healing.

374. To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

Dress each wound separately.

An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?

Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D).

366. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

Dry roasted almonds.

589. The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit?

Dyspnea, cough, and fatigue.

The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?

Early adolescence is a developmental stage of normal experimentation.

143. After applying a gait belt, the nurse assists a client with ambulation. While in the hallway , the client begins to fall. What action should the nurse implement? a. Advise the client to grab hold of the gait belt for support b. Ease the client to the floor while holding the gait belt securely c. Support the client in an upright position until the belt is removed d. Use the gait belt to slowly guide the client back to the room

Ease the client to the floor while holding the gait belt securely

The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client?

Eat 50% of six small meals each day by the end of one week.

59. Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Eat small meal throughout the day to avoid a full stomach.

After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Encourage a low carb and high protein diet

290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?

Encourage popsicles and fluids of choice

84. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

Eosinophils

91. When obtaining subjective data from a client, what intervention should the nurse implement first? a) List client problems b) Validate objective data c) Establish rapport d) Clarify inferences

Establish Rapport

144. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Establish a structured routine for the client to follow.

222. A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?

Establish trust with community leaders and respect cultural and family values

502. The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?

Evacuate each infant with mother via wheelchair

298. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care?

Evaluate closet proximal pulse.

352. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

Evaluate swallow

313. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?

Evaluate the client's mood, cognition and orientation.

114. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? a) Exercise at least three times weekly b) Monitor blood glucose levels daily c) Limit intake of foods high in saturated fat d) Learn to read all food product labels

Exercise at least three times weekly

587. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?

Exercise at least three times weekly

The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?

Exercise at least three times weekly

526. A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter's protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother's comment?

Explain that a protruding abdomen is typical for toddlers

369. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Explain that counseling will be provided to give her information about her cancer risk

101. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

Explain that the client may be placed in five positions

335. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?

Explain that the client will start to lose consciousness and his body system will slow down

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take?

Explain that the hand rub can be completed in less than 2 minutes.

586. A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications?

Explain that vomiting can occur during surgery Withhold the preoperative medication

70. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

Explore client's readiness to discuss the situation.

323. A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?

Explore the client's decision to refuse treatment and offer support

46. A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? a) Explain to the family that they must accept their Mother's decision b) Explore the client's decision to refuse treatment and offer support c) Discuss success of clinical trials and ask the client to consider participating for one month. d) Ask the client with her children present if she fully understands the decisions she has made.

Explore the client's decision to refuse treatment and offer support

602. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

Expresses an understanding of the procedure.

177. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

Fall prevention measures.

116. Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? a) Arterial ischemia b) Tissue necrosis c) Fat embolism d) Nerve damage

Fat embolism

568. Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication?

Fat embolism

364. The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation

138. A 41 week gestation primigravida is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusions of oxytocin (Pitocin)? a. Biophysical profile results showing oligohydramnios b. Sterile vaginal exam revealing 3 cm dilation c. Regular contractions occurring every 10 minutes d. Fetal heart tones locate in upper right quadrant

Fetal heart tones locate in upper right quadrant

165. The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?

Fever and dysuria.

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care?

Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate-controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management

A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide?

Five to seven days after menses cease. Due to the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is 5 to 7 days after menstruation stops (D) because physiologic alterations in breast size and activity reach their minimal level after menses.

5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

Further evaluation involving surgery may be needed

600. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

Get a blood pressure cuff.

211. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care?

Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% Evaluate heart rate for effectiveness of cardio tonic medications Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples Ensure Interrupted and frequent rest periods between procedures.

217. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?

Give a dose of regular insulin per sliding scale

Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?

Give one hour before or two hours after a meal.

71. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Glucose

92. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? a) Lactate b) Glucose c) Hemoglobin d) Creatinine

Glucose

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Glucose

56. The nurse is developing the plan of care for a hospitalized child with von Willebrand's disease. What priority nursing intervention should be included in this child's plan of care? A. Eliminate contact with cold drafts B. Reduce contact with other children C. Reduce exposure to infection D. Guard against bleeding injuries

Guard against bleeding injuries

389. A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask?

Has she taken a bath since the raped occurred?

551. Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority?

Have a meconium aspirator available at delivery

Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority?

Have a meconium aspirator available at delivery

48. The unit secretary in the emergency department reports to the charge nurse that a woman is outside at the entry to the hospital in a wheelchair with a broken liquor bottle and is cutting herself. What action should the nurse take? a) Have two nurses assess the woman for a psychiatric referral b) Have a security guard accompany the nurse to assess the woman c) Since the woman is outside the hospital, no nursing action is required. d) Have a male attendant take the woman to the observation unit.

Have a security guard accompany the nurse to assess the woman

282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?

Have the child lie with the ear up for one to two minute after installation.

565. An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care?

Have the client vocalize the instructions provided.

31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

Have you noticed any changes in your fingernails?

A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide?

Headache and hyperirritability are common.

Increased ICP S/S

Headache, vomiting, change in level of consciousness

28. In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? a) Heart rate of 92 beats per minute b) Systolic murmur c) Hematocrit of 28% d) Elevated parathyroid hormone level

Hematocrit of 28%

321. In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?

Hematocrit of 28%.

376. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

Hemoglobin

209. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?

Hemoglobin A1C (HbA1C) reading less than 7%

A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

How long has the client been taking the medication? Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication (A) provides information to direct additional instruction. (B, C, and D) are not relevant.

202. A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

How many departments can use this equipment?

During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first?

Identify the problem.

327. The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?

Identify the source and amount of bleeding.

Interventions for a client with a chest tube for pneumothorax?

If the tube becomes dislodged ask the patient to cough and exhale as much as possible.

306. The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?

Image

570. The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

Image

304. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?

Imbalance nutrition

100. An adult male is admitted to the psychiatric into from the emergency department because he is in the manic stage of bipolar disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been "trying to start a new business" and is "too busy to eat." He is alert and oriented to time, Place, and person, but not situation. Which nursing problem has the greatest priority? a) Disturbed sleep pattern b) Hygiene self-care deficit c) Self neglect d) Imbalanced nutrition

Imbalanced nutrition

Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?

Implements health programs for construction workers.

The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?

In developing organizational skills, medication administration is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be the priority in scheduling nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes precedence in providing care, the client's PRN need is less amenable to a preselected schedule. (B and C) can be scheduled around time-sensitive delivery of care.

594. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

Inability of the SA node to initiate an impulse at the normal rate

102. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile

The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?"

Inadequate lifestyle changes in diet and exercise.

275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required?

Increase ventilator rate.

In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition?

Increased thirst. (A) is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he or she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, (B) is not an appropriate measure of dehydration for a 3-year-old. The skin of a child with diabetes insipidus is usually warm and dry, not (C). (D) is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome.

The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?

Individual beliefs.

1. Folliculitis adverse reaction from a medication

Infection of hair follicles Drink with full glass of water

63. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response?

Inflammation of the mucous membrane & bronchospasm

40. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Inform her that some antianxiety medications are safe to take while breastfeeding

387. The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client?

Inform him that the nurse is busy admitting a new client and will talk to him later.

10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider

603. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?

Infuse sodium chloride 0.9% (normal saline)

102. What action should the school nurse implement to provide secondary prevention for school-aged children? a) Observe a type 1 diabetic self administer a dose of insulin b) Collaborate with a science teacher to prepare a health lesson c) Prepare a presentation on how to prevent the spread of lice d) Initiate a hearing and vision screening program for first graders.

Initiate a hearing and vision screening program for first graders.

338. What action should the school nurse implement to provide secondary prevention to a school-age children?

Initiate a hearing and vision screening program for first-graders

422. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

Initiate intravenous fluid as prescribed

198. A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?

Initiate seizure precautions

130. The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? a) Obtain a second IV access. b) Decrease the room temperature. c) Give the prescribed antiemetic. d) Insert an indwelling catheter.

Insert an indwelling catheter.

50. Which action should the school nurse take first when conducting a screening for scoliosis?

Inspect for symmetrical shoulder height.

442. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

Intravenous administration of thyroid hormones

545. An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can...to exhibit?

Irritability and a high-pitched cry

An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can the newborn...to exhibit?

Irritability and a high-pitched cry

480. The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug?

It blocks the effects of histamine, causing decreased secretion of acid

How do you assess myxedema? (Severely advanced hypothyroidism).

It often is possible to diagnose myxedema on clinical grounds alone. Characteristic symptoms are weakness, cold intolerance, mental and physical slowness, dry skin, typical facies, and hoarse voice. Results of the total serum thyroxine and free thyroxine index tests usually will confirm the diagnosis- they will be very low.

A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?

It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.

199. The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?

Jaundice

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?

Jaundice

Interventions for client with chest tube for pneumothorax?

Keep draingage below the patient chest level

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches

103. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches above the stoma

The nurse is visiting a senior client to complete a fall assessment. which observations indicate that the client would benefit from a instructions regarding balance and positioning( select all that apply) -

Knees are locked- weight is focused on the balls of the feet- weight is focused on the heels of the feet- chest is slightly further back than the abdomen

36. The client with which type of wound is most likely to need immediate intervention by the nurse?

Laceration

120. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Large amounts of fluid and electrolyte replacement.

401. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

Last menstrual period was 7 weeks ago

284. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?

Leave the catheter in place and obtain a sterile catheter.

419. A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?

Left forearm hematoma

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)?

Lethargy

357. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?

Level of consciousness

500. The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?

Long distance runner since high school.

621. The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter?

Long-term care facility Home health agency

A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?

Look for early signs of a lesion that increases in size with a red border, clear center. The client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center (B) at the site of the tick bite.

A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test?

Lumbar puncture

166. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Maintain both lower extremities elevated on pillows.

96. A male client who was discharged 3 days after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg.The nurse is preparing to initiate herparin therapy. What additional intervention should the nurse include in this client's plan of care? a) Maintain the client on bed rest b) Encourage a diet high in iron and ascorbic acid c) Encourage the client to dangle his legs frequently d) Administer the client's routine daily aspirin

Maintain client on bed rest

78. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.

Maintain contact transmission precaution

444. A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care?

Maintain effective breathing patterns

367. The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client?

Names 3 home safety hazards to be resolve immediately.

617. What is the nurse's priority goal when providing care for a 2-year-old child experience...

Manage the airway

448. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care?

Marinating pain level below 4 when implementing outpatient pain clinic strategies.

The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next?

Mark the drainage on the dressing and take vital signs. Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the 6 cm drainage on the dressing (A) assists in determining an increase in the amount which is supported with any changes in vital signs that indicates possible internal bleeding. (B) is premature. Removing the initial dressing may disturb the surgical site and increase the risk of hemorrhage and infection (C). (D) is compared with the previous amount of drainage marked on the dressing, so (A) is necessary.

544. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal...notifying the health care provider of the clients' condition, what information is most....

Maternal blood pressure

184. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Maternal pulse rate of 162 beats per min

A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)

Measure blood glucose Monitor vital signs Assessed level of consciousness

345. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)

Measure blood glucose Monitor vital signs Assessed level of consciousness

68. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

Measure hourly urinary output.

373. While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

Measure the area of swelling and crackling.

12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Medicare

173. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?

Medicate as needed for pain and anxiety.

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

Minimize noise in the newborn's environment

121. Which intervention should the nurse include in the plan of care for a child with tetanus?

Minimize the amount of stimuli in the room

273. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

Move obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure

435. An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)

Move personal items within client's reach Lower bed to the lower possible position Give directions to call for assistance Assist client to the bathroom in 2 hours.

481. A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...?

Mucous membranes cherry red color

A client with superficial burns to the face, neck, and hands resulting from a house fire... which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...?

Mucous membranes cherry red color

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse?

Muffled heart sounds

A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?

Multidisciplinary group.

26. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

Murmur

A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?

Nasal cannula.

101. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).

Near 5th intercostal space to the right of the nipple line

55. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement?

Negative pressure environment

558. A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

Negative pressure environment

87. One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?

Neurovascular and circulation compromise related to compartment syndrome.

180. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

New onset of purple skin lesions.

347. After receiving report, the nurse can most safely plan to assess which client last? The client with...

No postoperative drainage in the Jackson-Pratt drain with the bulb compressed

132. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)

Notify the food services department of the allergy. Enter the allergy information in the client's record. Add egg allergy to the client's allergy arm band.

485. When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next?

Notify the healthcare provider

383. Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take?

Notify the healthcare provider of the vomiting.

97. The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL. When assessing the client, what is the priority? a) Measure the level of acute pain b) Observe wound drainage characteristics c) Assess for signs of fluid volume deficit d) Determine when the client last ate

Observe wound drainage characteristics

A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having?

Obsessive

15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Obtain a clean catch mid-stream specimen

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Obtain a clean catch mid-stream specimen

The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Obtain a detailed report from the nurse transferring the client

Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take?

Perform hand hygiene

66. During a return demonstration of teaching provided by the nurse, the daughter of a client administers her mother's eye drops by resting her dominant hand on her mother's forehead and dropping the medication into the conjuctival sac. What action should the nurse take in response to this demonstration? a) Advise the daughter to keep her hand farther from her mother's eye b) Remind the client to gently close her eyes after the eye drops are instilled c) Offer to demonstrate the eye drop procedure to the daughter one more time d) Instruct the mother to gently rub the affected eye to distribute the drops

Offer to demonstrate the eye drop procedure to the daughter one more time

99. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning and preparing the client, rank the actions in the sequence they should be implemented, (place the first action at the top with the last action at the bottom.) a) Don sterile gloves and prepare the sterile field b) Open the sterile catheter kit close to the client's perineum c) Cleanse the urinary meatus using the solution, swabs, and forceps provided d) Place distal end of the catheter in sterile specimen cup and insert catheter in meatus

Open the sterile catheter kit close to the client's perineum Don sterile gloves and prepare the sterile field Cleanse the urinary meatus using the solution, swabs, and forceps provided Place distal end of the catheter in sterile specimen cup and insert catheter in meatus

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider

Persistent Fever

447. In assessing a pressure ulcer on a client's hip, which action should the nurse include?

Photograph the lesion with a ruler placed next to the lesion

409. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?

Picking up the second glove

391. The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended?

Place a client's locked wheelchair on the client's strong side next to the bed.

106. When caring for a client with deep partial-thickness burns to the posterior neck, which intervention should the nurse implement during the acute phase to prevent contractures at the site of injury? a) Place a towel roll under the client's neck or shoulder b) Passively raise arms above the head hourly while awake c) Actively turn head from side to side 90 degrees hourly d) Keep in supine position without the use of pillows

Place a towel roll under the client's neck or shoulder

483. The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

Place a washcloth in the sink while cleaning the dentures

If a child has a contagious respiratory disease, what needs to be done?

Place the child on airborne/droplet isolation precaution

135. The NURSE assesses a male client following surgery for a gunshot to the abdomen and determines that his dressing is saturated with blood and petechiae are on his extremities. His current BP is 80/40, and his heart rate is 130 beats/minute. Which lab finding confirms the presence of DIC? a) Low PT. b) Elevated fibrinogen. c) Positive d-Dimer. d) Normal hemoglobin.

Positive d-Dimer. Positive d dimer (also think PT PTT and decreased fibrinogen)

168. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

76. While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? a) Hemoglobin b) Potassium c) Protein d) Calcium

Potassium

302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)

Prepare a woman for a bone density screening

The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care?

Progressive leg exercises to obtain 90-degree flexion

90. While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement?

Promptly remove the arterial catheter from the radial artery.

218. The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?

Protect joint function

215. The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?

Provide a family tour of the preoperative unit one week before the surgery is scheduled.

A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?

Provide antiinflammatory response.

186. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care?

Provide daily care of tong insertion sites using saline and antibiotic ointment

122. A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? a) Administer epinephrine IV b) Give an IV bolus of amiodarone c) Provide immediate defibrillation d) Prepare for synchronized cardioversion

Provide immediate defibrillation

584. A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first?

Provide immediate defibrillation

341. A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action?

Provide only necessary information in short, simple explanations with written instructions to take home

124. Five days after surgical fixation of a fractured femur, a client suddenly complains of chest pain and difficulty breathing. The nurse suspects that the client may have had a pulmonary embolus. What action should the nurse take first? a) Notify the healthcare provider b) Prepare a continuous heparin infusion per protocol c) Provide supplemental oxygen d) Bring the emergency crash cart to the bedside

Provide supplemental oxygen

197. A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Provide the man and his mother with a copy of the Patient's Bill of Rights

611. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?

Psoriasis

83. A mother who is HIV positive asks the nurse about her infant's positive ELISA test. What information should the nurse provide to the mother? The infant has a) Converted to HIV positive status b) Received HIV maternal antibody transmission c) Developed CMV (cytomegalovirus) d) Been infected with congenital syphilis

Received HIV maternal antibody transmission

524. Which interventions should the nurse include in a long-term plan of care for a client with COPD?

Reduce risk factors for infection

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next?

Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading.

624. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take?

Remind the client to hold his breath after inhaling the medication

176. To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Remind the client to keep his appointments to have his cholesterol level checked.

103. A client who had a below-the-knee amputation is experiencing severe phantom limb pain (PLP) and asks the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? a) You can try mirror therapy, but do not expect complete elimination of the pain b) Research indicates that mirror therapy is effective in reducing phantom limb pain c) Where did you learn about the use of mirror therapy in treating phantom limb pain d) Trancutaneous electrical nerve stimulators (TENS) has been found to be more effective

Research indicates that mirror therapy is effective in reducing phantom limb pain

293. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful?

Research indicates that mirror therapy is effective in reducing phantom limb pain

A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful?

Research indicates that mirror therapy is effective in reducing phantom limb pain

1. Hyperventilating - acid base

Respiratory alkalosis

8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?

Respiratory apnea of 30 seconds

65. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply:

Restlessness Clenched Fist Increased pulse rate Increased respiratory rate.

283. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

Restrict daily fluid intake.

A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?

Rhinorrhoea or otorrhoea with Halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries.

469. A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

Risk for self-directed violence related to impulsive actions

Which med order for dementia patient requires intervention from the nurse?

Risperidone

394. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet?

Roasted turkey canned vegetables

83. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Serum potassium level of 3.1 mEq/L or mmol/L (SI)

The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?

Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D).

178. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis?

Shock

193. A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?

Simethicone (Mylicon)

56. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Sitting up and leaning forward

100. A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?

Skills of staff and client acuity

36. When evaluating the discharge teaching for a male client who is taking diclofenac (Zipsor), the nurse knows the teaching was effective if the client states that he will stop taking the drug and notify the healthcare provider if which symptom occurs? a) Indigestion b) Skin rash c) Nervousness d) Insomnia

Skin rash

The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with

Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock.

438. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first?

Stabilize the victim's neck and roll over to evaluate his status

98. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? a) Examine the victim's body surfaces for arterial bleeding b) Stabilize the victim's neck and roll over to evaluate his status c) Return to the car to call emergency response 911 for help d) Open the airway and initiate resuscitative measures

Stabilize the victim's neck and roll over to evaluate his status

When engaging in planned change on the unit, what should the nurse-manager establish first?

Staff members are aware of the need for change.

41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Start an intravenous (IV) infusion of normal saline

The scope of professional nursing practice is determined by rules promulgated by which organization?

State's Board of Nursing.

44. After a coronary artery bypass graft, a client is discharged home with a referral for care and cardiac rehabilitation. Which assessment should the nurse obtain for this client's tertiary prevention? a. Historical changes in lifestyle and compliance with medical recommendations. b. Status of the client's incisions an indications of postoperative complications c. Symptoms of exacerbation or progression of the underlying cardiac disease d. The client's tolerance to exercise progression and psychosocial adaptation

Status of the client's incisions an indications of postoperative complications

Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?

Stimulate contraction of the uterus.

A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?

Stop the code immediately.

109. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Stop the normal saline infusion.

21. The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide?

Stop using the ointment and encourage complete drying of the feet and wearing clean socks.

628. When administering ceftriaxone sodium (Rocephin) intravenously to a client before...most immediate intervention by the nurse?

Stridor

410. A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?

Stroke

2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

Stroke secondary to hemorrhage

151. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?

Submit a referral for an evaluation by a physical therapist.

510. The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer's diseases. The client's wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?

Suggest enrolling the client in adult daycare instead of rotating among family.

127. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Supervise a newly hired graduate nurse during an admission assessment.

507. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

Supervised a newly hired graduate nurse during an admission assessment

The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis?

Swimming lessons in an indoor pool.

534. While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated....persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

T4 levels in newborns

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client‟s teaching plan?

Take on an empty stomach with a full glass of water

A female client receives a prescription for alendronate sodium (fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include the clients teaching plan

Take on an empty stomach with a full glass of water

137. The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)

Take postoperative vital signs for a client who has an epidual following knee arthroplasty Collect a sputum specimen for a client with a fever of unknown origin Ambulate a client who had a femoral-popliteal bypass graft yesterday

The nurse has taught a patient who was admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse determines that additional teaching is necessary when the patient makes which statement

Taking a hot bath every day will help with my circulation."

During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?

Taking medication, with community follow-up.

146. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bridge. What actions in the treatment plan should the nurse implement? a. Teach client to listen to music or audio books while driving b. Encourage client to have spouse drive in stressful places c. Tell client to drive over the bridge until fear is manageable d. Recommend that the client avoid driving over the bridge

Teach client to listen to music or audio books while driving

396. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care?

Teach need for dietary and supplementary vitamin D3

139. Which intervention should the nurse include in the preparation of a client who is scheduled for gastric bypass surgery? a. Encourage the family to participate in monitoring the client's dietary intake. b. Suggest avoiding shopping for food by designating someone to grocery shop. c. Teach the client how to prepare small meals that are low in fat and sugar. d. Advise the client's family to seek dietary counseling and exercise planning.

Teach the client how to prepare small meals that are low in fat and sugar.

6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?

The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders.

The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?

The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake.

580. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain?

Therapeutic exercise included in daily routine.

343. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome?

Thiamine (Vitamin B1)

A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?

This anti-estrogen drug inhibits malignancy growth. Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women (B), and is classified as a hormonal agent, not (D), used to suppress malignant cell growth.

The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?

This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with these symptoms.

351. A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide?

This hernia is a normal variation that resolves without treatment.

331. Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?

Transfuse Type A negative blood until type AB negative is available.

569. A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size?

Thready brachial pulse.

308. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is

Three days postoperative colon resection receiving transfusion of packed RBCs.

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

Time the medication was given The nurse should document the time, the name of the med, the dose, and the route in which the med was given on the client's MAR immediately after it was administered. The nurse should also document the time that the incorrect med was administered to the client in the incident report, as this is a fact directly related to the occurrence.

312. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement?

Titrate the dopamine infusion to raise the BP.

A nurse is teaching a patient with bulimia nervosa about scheduling healthy, balanced meals:

To avoid binge-purge cycles

13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

Toasted wheat bread and jelly

547. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What...

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded

528. A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?

Unresponsive to painful stimuli

543. A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

Urinary output of 25mL per hour

Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?

Use a sanitary napkin instead of a tampon. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported.

477. A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?

Use a secondary port of the Normal Saline solution to administer the antibiotic.

The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?

Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.

14. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? a) Ask the mother what she usually uses on the child's lips and nose b) Apply a petroleum jelly (Vaseline) to the child's nose and lips c) Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips d) Use a water soluble lubricant on affected oral and nasal mucosa

Use a water soluble lubricant on affected oral and nasal mucosa

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. which client with which change in status is best to assign to the PN?

Viral meningitis whose temperature changed from 101° F ( 38.3 C) to 102° F (38.9C

194. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?

Vitamin supplements for high-risk pregnant women.

1. Korotkoff-sounds BP

Wait 1 minute and palpate the systolic pressure before auscultating again

The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?

Wanting the drug is all that matters to an addict.

408. A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include?

Wash hands before cleaning exit site

392. A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication?

Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site.

615. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

What food does your baby usually eat in a normal day?

A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next?

When did the symptoms begin after the last dose of opiate analgesic? Moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea, muscle cramps, and elevated blood pressures greater than 110 systolic or 70 diastolic. The onset of withdrawal for opiate analgesics typically coincides with the time of the next habitual drug dose at 4-6 hours and may last as long as 7 to 14 days, so determining the time of the last dose (D) pinpoints the relationship of opiate dependency and withdrawal symptoms.

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based handrub is appropriate in which of the following situations?

When hands are visibly soiled

54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

White blood cell (WBC) count Sputum culture and sensitivity

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

White blood cell (WBC) count Sputum culture and sensitivity

272. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client

Who is confused and frequently forgets to go to the bathroom

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure

65. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? a) Initiate IV fluid replacement b) Evaluate intake and output ratio c) Administer antiemetics as needed d) Withhold food and fluid intake

Withhold food and fluid intake

317. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Withhold food and fluid intake.

The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?

Withhold the medication and contact the healthcare provider. Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity.

113. A mother calls the nurse to report at 0900 she administered a PO dose of digoxin (Lanoxin) to her 4-month-old infant, but at 0920 the baby vomited the medicine. What instruction should the nurse provide to this mother? a) Administer a half dose now b) Mix the next dose with food c) Give another dose d) Withhold this dose

Withhold this dose

A patient is receiving antiretroviral therapy (ART). Which outcome indicates a therapeutic response to the medication therapy? A) elevation of HIV RNA levels B) CD4 T-cell increase C) decreased T-cell reactivity D) increased immune system functioning

b

Lantus (insulin glargine)

long acting insulin

The nurse is providing care for a client with small-cell carcinoma of the lung who develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply. A) Edema B) Polyuria C) Bradycardia D) Hypotension E) Hyponatremia

A) Edema E) Hyponatremia - Edema results as fluid is retained because of the increased secretion of antidiuretic hormone. ADH causes water retention, which dilutes serum electrolytes such as sodium, with a resultant hyponatremia. A decreased urine output occurs with SIADH because ADH causes reabsorption of fluid in the kidney glomeruli. The increased fluid volume associated with SIADH results in tachycardia, tachypnea, and crackles. The increased fluid volume associated with SIADH results in hypertension, not hypotension.

Fludrocortisone is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse instruct the client to report? Select all that apply. A) Edema B) Rapid weight gain C) Fatigue in the afternoon D) Unpredictable changes in mood E) Increased frequency of urination

A) Edema B) Rapid weight gain

A client is diagnosed with hyperthyroidism and is experincing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply. A) Use tinted glasses B) Use warm, moist compresses C) Elevated the HOB 45 degrees D) Tape eyelids shut at night if they do not close E) Apply a petroleum-based jelly along the lower eyelid

A) Use tinted glasses C) Elevated the HOB 45 degrees D) Tape eyelids shut at night if they do not close

A client with a brain tumor develops a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which nursing intervention is the most appropriate to perform for this client? A) Evaluate urine specific gravity. B) Implement fluid restrictions. C) Provide emollients to the skin to prevent breakdown. D) Slow down the intravenous (IV) fluids and notify the primary healthcare provider

A) Evaluate urine specific gravity. - Urine output of 300 mL/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There is no indication to reduce fluids. Providing emollients to prevent skin breakdown is important but does not assist with determining the underlying cause of the increased urine output. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? Select all that apply. A) Examining the feet daily B) Wearing well-fitting shoes C) Performing regular exercise D) Powdering the feet after showering E) Visiting the HCP weekly F) Testing bathwater with the toes before bathing

A) Examining the feet daily B) Wearing well-fitting shoes C) Performing regular exercise

A client has a thyroidectomy for cancer of the thyroid. When evaluating for nerve injury, what should the client be asked to do? A) Speak B) Swallow C) Purse the lips D) Turn the head

A) Speak - The laryngeal nerve is close to the operative site and can be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. The ability to purse the lips tests the seventh cranial (facial) nerve, which is not affected in thyroid surgery. The nerves involved in turning the head are not near the thyroid gland.

A client admitted to the ED has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client? A) Starvation B) Alcoholism C) Bone healing D) Positive nitrogen balance

A) Starvation - In starvation there are inadequate carbohydrates available for immediate energy, and stored fats are used in excessive amounts, producing ketones.

The nurse is teaching a nursing student about caring for a client who is undergoing blood studies for antidiuretic hormone stimulation. Which statements made by the nursing student indicate effective instruction? Select all that apply. A) "I will assess the pulse rate after rehydrating the client." B) "I will perform the test if the serum sodium level is high." C) "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." D) "I will hydrate the client with oral fluids before performing the test." E) "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)."

A) "I will assess the pulse rate after rehydrating the client." C) "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." E) "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)." - The client's pulse rate and blood pressure should be assessed after rehydration for orthostatic hypertension after the procedure to ensure adequate fluid volume. The test should be performed if the serum osmolarity is less than 300 mOsm (mmol)/kg to avoid severe dehydration in clients who have central or nephrogenic diabetes insipidus. The test should be discontinued if the client's weight loss is greater than 2 kg. The test should not be performed if the serum sodium levels are high because severe dehydration may develop in central or nephrogenic diabetes insipidus clients. The client should have nothing by mouth before the test. Oral fluids are given to the client to rehydrate if the client is experiencing dehydration during the test.

After assessing a client, the nurse anticipates that the client has hyperpituitarism. Which questions asked by the nurse helps confirm the diagnosis? Select all that apply. A) "Is there any change in your vision?" B) "Do you experience severe headaches?" C) "Are you suffering with frequent urination?" D) "Do you eat more than five times a day?" E) "Is there any change in your menstrual cycle?

A) "Is there any change in your vision?" B) "Do you experience severe headaches?" E) "Is there any change in your menstrual cycle? - Hyperpituitarism manifests with vision disturbances and severe headaches. Due to hypersecretion of prolactin in females, a change in menstrual cycle may also be observed. Frequent urination is observed in a client with diabetes insipidus. Clients with diabetes mellitus experience intense hunger.

A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse's best response to this question? A) "There is no difference between readings." B) These types of monitors are meant for children." C) "Readings are on a different scale for each monitor." D) "Faster readings can be obtained from a fingerstick."

A) "There is no difference between readings."

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? A) Ammonia level B) Culture and sensitivity C) WBC count D) AST level

A) Ammonia level

A nurse is providing discharge instructions for a client with a diagnosis of GERD. What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply. A) Avoid heavy lifting B) Lie down after eating C) Avoid drinking alcohol D) Eat small, frequent meals E) Increase fluid intake with meals F) Wear an abdominal binder or girdle

A) Avoid heavy lifting C) Avoid drinking alcohol D) Eat small, frequent meals

A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner? A) Checking the client's serum glucose level B) Assisting the client out of bed into a chair C) Placing the client in the high-Fowler position D) Ensuring the client's residual limb is elevated

A) Checking the client's serum glucose level - Because the client has type 1 diabetes, it is essential that the blood glucose level be determined before meals to evaluate the level of control of diabetes and the possible need for insulin coverage. To prevent flexion contractures of the hip, the client should not sit for a prolonged time; this is not the priority. Raising the head of the bed flexes the hips, which may result in hip flexion contractures; this is not the priority. Ensuring the client's residual limb is elevated may result in a hip flexion contracture and should be avoided.

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. A) Cool skin B) Photophobia C) Constipation D) Periorbital edema E) Decreased appetite

A) Cool skin C) Constipation D) Periorbital edema E) Decreased appetite - Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. A) Diarrhea B) Listlessness C) Weight loss D) Bradycardia E) Decreased appetite

A) Diarrhea C) Weight loss

A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestation should the nurse expect when assessing this client? Select all that apply. A) Dry skin B) Brittle hair C) Weight loss D) Resting tremors E) Heat intolerance

A) Dry skin B) Brittle hair

A nurse is caring for a client with cholelithasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indication associated with this condition? Select all that apply. A) Ecchymosis B) Yellow sclera C) Dark brown stool D) Straw-colored urine E) Pain in the right upper quadrant

A) Ecchymosis B) Yellow sclera E) Pain in the right upper quadrant

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infections process does the nurse conclude is impaired as a result of this disease? A) Stress response B) Electrolyte balance C) Metabolic process D) Respiratory function

A) Stress response - Because of diminished glucocorticoid production, there is a decreased response to stress, reducing the ability to fight infection.

A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply. A) Fatigue B) Dry skin C) Insomnia D) Intolerance to heat E) Progressive weight gain

A) Fatigue B) Dry skin E) Progressive weight gain - Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.

A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit. Select all that apply. A) Fever B) Hyperactivity C) Extreme hunger D) Urinary retention E) Abdominal muscle rigidity

A) Fever D) Urinary retention

An active adolescent is admitted to the hospital for surgery for an ileostomy. WHen planning a teaching session about self-care, the nurse includes sports that should be avoided by this client. Which should be included on the list of sports to avoid? Select all that apply. A) Football B) Swimming C) Ice hockey D) Track events E) Cross-country skiing

A) Football C) Ice hockey

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. A) Hirsutism B) Menorrhagia C) Buffalo hump D) Dependent edema E) Migraine headaches

A) Hirsutism C) Buffalo hump

A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated? A) Hypotension B) Hyperglycemia C) Sodium retention D) Potassium excretion

A) Hypotension - After an adrenalectomy, adrenal insufficiency causes hypotension because of fluid and electrolyte imbalances.

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply. A) Lability of mood B) Slow wound healing C) A decrease in the growth of hair D) Ectomorphism with a moon face E) An increased resistance to bruising

A) Lability of mood B) Slow wound healing

Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis? A) Monitoring for signs of hypoglycemia as a result of treatment B) Withholding glucose in any form until the situation is corrected C) Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally D) Regulating insulin dosage according to the amount of ketones found in the client's urine

A) Monitoring for signs of hypoglycemia as a result of treatment - During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Whole milk and fruit juices are high in carbohydrates which are contraindicated in DKA (Option C).

A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamin has to be given IV rather than by mouth. What rationals for this route should the nurse include in a response to the question? Select all that apply. A) More rapid action results B) They are ineffective orally C) They decrease colon irritability D) Intestinal absorption may be inadequate E) Allergic responses are less likely to occur

A) More rapid action results B) They are ineffective orally D) Intestinal absorption may be inadequate

Thiamine (Vitamin B1) and niacin (Vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? A) Neuronal activity B) Bowel elimination C) Efficient circulation D) Prothrombin development

A) Neuronal activity

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? A) Receives long-term steroid therapy B) Has a history of hypoparathyroidism C) Engages in strenuous physical activity D) Consumes high doses of the hormone estrogen

A) Receives long-term steroid therapy - Increased levels of steroids increase bone demineralization.

A client with diabetes states, "I cannot eat big meals; I prefer to snack throughout the day." What information should the nurse include in a response to this client's statement? A) Regulated food intake is basic to control B) Salt and sugar restriction is the main concern C) Small, frequent meals are better for digestion D) Large meals can contribute to weight problems

A) Regulated food intake is basic to control

The nurse is assessing a client admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these are signs of Cushing disease? Select all that apply. A) Round face B) Dependent edema in the feet and ankles C) Increased fatty deposition in the extremities D) Thin, translucent skin with bruising E) Increased fatty deposition in the neck and back

A) Round face B) Dependent edema in the feet and ankles D) Thin, translucent skin with bruising E) Increased fatty deposition in the neck and back - Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition. Hypertension, not hypotension, is expected because of sodium and water retention.

A client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? Select all that apply. A) Soft diet B) Regular diet C) Low-protein diet D) High-protein diet E) Low-carbohydrate diet F) High-carbohydrate diet

A) Soft diet D) High-protein diet F) High-carbohydrate diet

An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A NG tube to suction is in place. What should the nurse expect regarding the client's NG tube drainage during the first 24 hours after surgery? A) Green and viscid B) Contain some blood and clots C) Contain large amounts of frank blood D) Similar to coffee grounds in color and consistency

B) Contain some blood and clots

A nurse is obtaining a history and performing a physical assessment of a client who has cancer of the tongue. Which clinical findings should the nurse expect to identify? Select all that apply. A) Halitosis B) Leukoplakia C) Bleeding gums D) Substernal pain E) Alterations in taste F) Enlarged cervical lymph nodes

B) Leukoplakia E) Alterations in taste F) Enlarged cervical lymph nodes

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply. A) Thirst B) Palpitations C) Diaphoresis D) Slurred speech E) Hyperventilation

B) Palpitations C) Diaphoresis D) Slurred speech

A nurse is caring for a postoperative client who has diabetes. WHich is the MOST common cause of DKA that the nurse needs to consider when caring for this client? A) Emotional stress B) Presence of infection C) Increased insulin dose D) Inadequate food intake

B) Presence of infection

A registered nurse is teaching the student nurse the precautions to follow when blood samples are collected. Which statement made by the student nurse indicates effective learning? A) "I can place the specimen with other samples." B) "I can use a single-lumen line to obtain samples." C) "I should not reveal the test procedure to the client." D) "I should not place the blood samples collected for adrenaline on ice."

B) "I can use a single-lumen line to obtain samples." - Usage of double- or triple-lumen lines for obtaining samples may contaminate the sample. Therefore, only single-lumen lines should be used. The samples should be stored separately to avoid contamination. The procedure of testing should be discussed with the client to obtain proper results. Blood samples drawn for catecholamines must be placed on ice and taken to the laboratory immediately.

A client is learning alternative site testing for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary? A) "I need to rub my forearm vigorously until warm before testing at this site." B) "The fingertip is prefered for glucose monitoring if hyperglycemia is suspected." C) "Alternative site testing is unsafe if I am experiencing a rapid change in glucose levels." D) "I have to make sure that my current glucose monitor can be used at an alternative site."

B) "The fingertip is prefered for glucose monitoring if hyperglycemia is suspected." - The fingertip is prefered for glucose monitoring if HYPOGLYCEMIA is suspected, not hyperglycemia.

A Harris flush is ordered to reduce a client's flatus after abdominal surgery. How many inches should the nurse insert the rectal catheter? A) 2 B) 4 C) 6 D) 8

B) 4

A client with a family history of goiter is experiencing changes in voice and breathing. Which diagnostic study does the nurse consider to be beneficial in confirming a diagnosis? A) Thyroglobulin B) Thyroid antibodies C) Thyroxine (free T4), total D) Thyroid-stimulating hormone (TSH)

B) Thyroid antibodies - Changes in voice and breathing can be seen in Hashimoto's thyroiditis if the thyroid gland enlarges rapidly and constricts the trachea and laryngeal nerves. Clients with a family history of goiter may have this condition. A thyroid antibody test is used diagnose Hashimoto's thyroiditis by differentiating thyroid dysfunction from thyroiditis. Thyroglobulin is used to detect thyroid cancer. Thyroxine (free T4), total and TSH are used to evaluate thyroid function.

A client has a fractured mandible that is immobilized by wires. For which life-threatening postoperative problem should the nurse monitor this client? A) Infection B) Vomiting C) Osteomyelitis D) Bronchospasm

B) Vomiting

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies further teaching about the hypophysectomy is necessary when the client states, "I know I will.. A) be sterile for the rest of my life." B) require larger doses of insulin than I did preoperatively." C) have to take cortisone or a similar drug for the rest of my life." D) have to take thyroxine or a similar medication for the rest of my life"

B) require larger doses of insulin than I did preoperatively." - The hypophysis (pituitary gland) does not directly regulate insulin release. This is controlled by serum glucose levels. Because somatotropin release will stop after the hypophysectomy, any elevation of blood glucose level caused by somatotropin will also stop.

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer? A) Unexplained shock B) Melena for several days C) A sudden massive hemorrhage D) A gradual drop in the hematocrit value

C) A sudden massive hemorrhage - Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. Sudden massive bleeding occurs, not the slow oozing that causes melena. A gradual drop in the hematocrit value indicates slow blood loss.

A client with cancer of the colon had surgery for a resection of the tumor and the creation of a colostomy. During the 6-week postoperative checkup, the nurse teaches the client about nutrition. The nurse evaluates that learning has taken place when the client states, "I should follow a diet that is: A) Rich in protein B) Low in fiber content C) As close to usual as possible D) Higher in calories than before

C) As close to usual as possible

A HCP orders a GI endoscopy with a capsule endoscopic device. What should the nurse instruct the client to do? A) Check the recorder every hour B) Avoid eating food and fluid during the test C) Avoid stooping and bending during the test D) Swallow the capsule as soon as it is placed in the mouth

C) Avoid stooping and bending during the test

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's NG tube is bright red. What should the nurse do first? A) Notify the HCP B) Clamp the NG tube for one hour C) Determine that this is an expected finding D) Irrigate the NG tube with iced saline

C) Determine that this is an expected finding

A client who had an I+D of an oral abscess is to be discharged. For which clinical finding, if it should occur, should the nurse instruct the client to notify the HCP? A) Foul odor to the breath B) Pain associated with swallowing C) Pain with swelling after one week D) Tenderness in the mouth when chewing

C) Pain with swelling after one week - Pain and swelling should subside before one week. Continued pain and swelling may indicate infection.

A client is admitted to a medical unit with a diagnosis of Addison disease. The client is emaciated and reports muscular weakness and fatigue. Which disturbed body process does the nurse determine is the root cause of the client's clinical manifestations? A) Fluid balance B) Electrolyte levels C) Protein anabolism D) Masculinizing hormones

C) Protein anabolism - Glucocorticoids help maintain blood glucose and liver and muscle glycogen content. A deficiency of glucocorticoids causes hypoglycemia, resulting in the breakdown of protein and fats as energy sources.

A HCP orders an upper GI series and a barium enema. The client asks, "Why do I have to have barium for these tests?" The nurse's best response is "Barium: A) gives off visible light, illuminating the alimentary tract" B) provides fluorescence, thereby lighting up the alimentary tract" C) dyes the structures of the alimentary tract, making them more visible" D) gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."

D) gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."

The nurse is caring for a client who is diagnosed with hyperpituitarism due to a prolactin-secreting tumor. Which clinical manifestation can help confirm the diagnosis? A) Hypertrophy of skin B) Enlargement of liver C) Hypertrophy of the heart D) Absence of menstruation

D) Absence of menstruation - A prolactin-secreting tumor is a common type of pituitary adenoma that results from excessive secretion of prolactin. Therefore, ultimately, there are associated clinical symptoms, such as absence of galactorrhea and menstruation and infertility. Excessive production of growth hormone is manifested by clinical symptoms, such as skin hypertrophy and enlargement of organs (e.g., liver and heart).

A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. What clinical manifestations might the nurse identify when assessing this client? Select all that apply. A) Muscle tremors B) Abdominal cramps C) Increased peristalsis D) Cardiac dysrhythmias E) Hypoactive bowel sounds

D) Cardiac dysrhythmias E) Hypoactive bowel sounds - When the serum calcium level is increased, initially it causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia. Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds. Muscle tremors occur with hypocalcemia, not hypercalcemia. Abdominal cramps occur with hypocalcemia, not hypercalcemia. Increased intestinal peristalsis occurs with hypocalcemia, not hypercalcemia.

A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs? A) Give the client 8 oz (240 mL) of orange juice. B) Seek a prescription to increase the insulin dose at bedtime. C) Encourage the client to eat smaller, more frequent meals. D) Collaborate with the primary healthcare provider to alter the insulin prescription

D) Collaborate with the primary healthcare provider to alter the insulin prescription - The client is experiencing the Somogyi effect. It is a paradoxical situation in which sudden decreases in blood glucose are followed by rebound hyperglycemia. The body responds to the hypoglycemia by secreting glucagon, epinephrine, growth hormone, and cortisol to counteract the low blood sugar; this results in an excessive increase in the blood glucose level. It most often occurs in response to hypoglycemia when asleep. The primary healthcare provider may choose to decrease the insulin dose and then reassess the client. Giving the client 8 oz (240 mL) of orange juice will further increase the serum glucose level and is contraindicated. Increasing the insulin dose at bedtime will further worsen the problem. Encouraging the client to eat smaller, more frequent meals will not address the hypoglycemia and rebound hyperglycemia that occurs when sleeping. However, a bedtime snack may help minimize this event.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Of the additional assessment findings, which one should the nurse report to the practitioner? A) Increased appetite B) Recent weight loss C) Feelings of warmth D) Fluttering in the chest

D) Fluttering in the chest - Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.

A nurse is teaching an athletic teenager about nutrients that provide the quickest source of energy. Which food selected from the menu indicates to the nurse that the adolescent understands the teaching? A) Glass of milk B) Slice of bread C) Chocolate candy bar D) Glass of orange juice

D) Glass of orange juice

What are the cardiovascular manifestations observed in a client with adrenal insufficiency? A) Fatigue B) Salt craving C) Weight loss D) Hyponatremia

D) Hyponatremia - Hyponatremia is a decrease in serum sodium levels, which is the cardiovascular manifestation of adrenal insufficiency. Fatigue is a neuromuscular manifestation observed in clients with adrenal insufficiency, while salt cravings and weight loss are the abdominal manifestations observed in clients with adrenal insufficiency.

A client with esophageal cancer is to receive TPN. A right subclavian catheter is inserted. What is the primary reason why the HCP ordered a central line? A) It prevents the development of infection B) There is less chance of this infusion infiltrating C) It is more convenient so clients can use their hands D) The large amount of blood helps to dilate the concentrated solution

D) The large amount of blood helps to dilate the concentrated solution