Fundamentals of Nursing Exam 4

A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? a. Wear gloves when changing the client's gown b. Use alcohol-based sanitizer to cleanse the hands c. Wear a mask when assisting the client with his meal tray d. Place the client on complete bed rest

a Rationale: The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client in contact isolation. The nurse should use soap and water to cleanse the hands. Alcohol-based hand sanitizer is ineffective against the spores of C. difficile. The nurse should wear a mask when working within 3 feet of a client who has an infection, and droplet precautions are required. The nurse should not place the client on complete bed rest because this places him at risk for the hazards of immobility, such as impaired skin integrity and retained respiratory secretions. The nurse should instruct the client to remain in his room but to move, cough, and deep breathe at least every 2 hours.

A nurse is monitoring a client who takes aspirin daily. The nurse should identify which of the following manifestations as adverse effects of aspirin? Select all that apply. a. Hypertension b. Coffee-ground emesis c. Tinnitus d. Paresthesias of the extremities e. Nausea

b, c, e Rationale: Dark stools or coffee-ground emesis indicate GI bleeding, nausea, vomiting, abdominal pain, and tinnitus and hearing loss all can occur as an adverse effect aspirin therapy. Hypotension and shock can resu.t if an aspirin allergy occurs but hypertension and paresthesias of the extremities are not adverse effects of aspirin therapy.

A nurse is planning to administer morphine IV to a client who is postoperative. Which of the following actions should the nurse take? a. Monitor for seizures and confusion b. Protect the client's skin from the severe diarrhea that occurs with morphine c. Withhold this medication if respiratory rate is less than 12/min d. Give morphine intermittent via IV bolus over 30 seconds or less

c Rationale: Withhold all opioids if the respiratory rate is less than 12/min. Constipation is more associated with morphine than diarrhea. Administer an IV bolus slowly over 3 to 5 min to determine the client's response, and monitor blood pressure and respiration rate. When administering repeated doses of meperidine, a toxic metabolite can build up and cause severe CNS effects (agitation, confusion, and seizures).

A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of this medication? 1. Impotence 2. Mood swings 3. Increased appetite 4. Complete atrioventricular (AV) block

1 Rationale: A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects occur rarely and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.

A client diagnosed with hypertension has been prescribed Captopril. The nurse determines that the client understands how to take this medication appropriately when stating the intention to take which action while taking this medication? 1. Sitting and standing up slowly 2. Drinking large amounts of water 3. Eating foods that are high in potassium 4. Taking in large amounts of high-fiber foods

1 Rationale: Captopril is an antihypertensive medication (angiotensin-converting enzyme inhibitor). Orthostatic hypotension is a concern for clients taking antihypertensive medications. Clients are advised to avoid standing in one position for lengthy periods of time, to change positions slowly, and to avoid extreme warmth (showers, bath, and weather). Clients are also taught to recognize the symptoms of orthostatic hypotension, including dizziness, light-headedness, weakness, and syncope. Option 2 could aggravate the hypertension, whereas the other options are not necessary when considering the medication.

The nurse instructs a client with a diagnosis of atrial fibrillation who has been prescribed warfarin to use an electric razor for shaving. Which premise best supports the rationale for this instruction? 1. Cuts need to be avoided 2. Any cut may cause infection 3. Electric razors can be disinfected 4. All straight razors contain bacteria

1 Rationale: Clients with atrial fibrillation are placed on anticoagulants to prevent thrombus formation and possible stroke. Therefore, measures to prevent bleeding need to be taught to the client. The importance of use of an electric razor is to prevent cuts and possible bleeding. Not all cuts cause infection. Electric razors can be cleaned but usually cannot be disinfected. Not all straight razors contain bacteria. Additionally, options 2, 3, and 4 are all unrelated to the subject of bleeding; rather, they relate to infection.

A client with hypertension has received a prescription for lisinopril. The nurse teaches the client that which frequent side effect may occur? 1. Cough 2. Polyuria 3. Hypothermia 4. Hypertension

1 Rationale: Cough is a frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors. Fever is an occasional side effect. Proteinuria is another common side effect, but polyuria is not. Hypertension is the reason to administer the medication rather than a side effect.

Which clinical situation would the nurse identify as an example of slander? 1. The primary health care provider tells a client that the nurse "does not know anything" 2. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat 3. The nurse restrains a client at bedtime because the client gets up during the night and wanders around 4. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained

1 Rationale: Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.

A client experiencing difficulty breathing and increased pulmonary congestion as a result of heart failure was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment finding indicates that the therapy has been effective? 1. The lungs are now clear upon auscultation 2. The urine output has increased by 400 mL 3. The blood pressure has decreased from 118/64 to 106/62 mmHg 4. The serum potassium has decreased from 4.7 to 4.1 mEq

1 Rationale: Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason that the furosemide was administered.

After furosemide is prescribed, the nurse provides medication instructions to the client that include taking the medication at which time? 1. With breakfast 2. With the supper meal 3. Immediately before bedtime 4. Midafternoon on an empty stomach

1 Rationale: Furosemide is a loop diuretic, It should be administered with food to prevent gastrointestinal upset. It is best taken in the morning with breakfast to prevent nocturia.

The nurse monitoring a client with a deep vein thrombosis who has been prescribed a heparin infusion determines that the client is experiencing a complication of therapy when which finding is noted? 1. Dark, tarry stools 2. Reports of extreme fatigue 3. Reports of nausea with dry heaves 4. Respiratory rate of 18 breaths per minute

1 Rationale: Heparin is an anticoagulant that can cause bleeding as an adverse effect. The nurse would monitor the client for abdominal pain or swelling, backache, dizziness, headache, hematemesis, hemoptysis, hematuria, black or tarry stools, and Hematest-positive urine/stool or nasogastric drainage. Overt signs include ecchymoses; petechiae; hematomas; nosebleeds; and bleeding from gums, wounds, or invasive line insertions sites.

A client diagnosed with pulmonary edema is treated with furosemide. The nurse determines that the medication is effective when which assessment finding is noted? 1. Lung sounds are clear 2. Hourly urinary output is 30 mL 3. Blood pressure is 120/82 mmHg 4. Potassium level is 3.6 mEq/L

1 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. The left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of accumulated blood. Early signs and symptoms include crackles in the lung bases, dyspnea at rest, disorientation, and confusion. Furosemide is prescribed because it is a rapid-acting diuretic. In pulmonary edema, an effective response to furosemide would be indicated by clear breath sounds. Although a potassium level of 3.6 mEq/L is normal, it is unrelated to the effectiveness of furosemide in a client with pulmonary edema. In pulmonary edema, the urinary output response to furosemide should be greater than 30 mL/hour. A blood pressure of 120/82 mmHg is near normal but does not indicate effectiveness of furosemide in pulmonary edema.

The home care nurse provides medication instructions concerning the administration of warfarin for a client diagnosed with atrial fibrillation. Which statement by the client indicates the need for further teaching? 1. "My urine will change to reddish orange" 2. "This medicine will still be working 4 to 5 days after it is discontinued" 3. "This medication will require blood work frequently to monitor its effects" 4. "I can't take any aspirin-containing medications while I'm on this medication"

1 Rationale: Warfarin is an anticoagulant. Bleeding is a concern while the client is taking this medication. Reddish-orange urine could indicate blood in the urine as an adverse effect of the medication. Bleeding may also be identified by urine that turns smoky colored or black. All the remaining options are correct statements regarding this medication. The half-life of the medication is 2 days, the peak effect is between 1 and 3 days, and the anticoagulant effect extends 4 to 5 days after discontinuation. The prothrombin time (PT) or International Normalized Ratio (INR) are laboratory tests that may be used to monitor the clotting mechanism and effectiveness of the medication. Aspirin is an antiplatelet agent and would increase the risk of bleeding.

The nurse is delegating unit nursing tasks for the day. Which tasks would the nurse delegate to the assistive personnel (AP)? Select all that apply? 1. Deliver fresh water to clients 2. Empty urine out of Foley bags 3. Take temperatures, pulses, respirations, and blood pressures 4. Count the substance control medications in the opioid medication supply 5. Check the crash cart (cardiopulmonary resuscitation cart) for necessary supplies using a checklist 6. Check all intravenous (IV) solution bags on clients receiving IV therapy for the remaining amounts of the solution in the bags.

1, 2, 3 Rationale: When delegating an activity, the nurse must consider the educational preparation and experience of the individual. The AP is trained to perform noninvasive tasks and those that meet basic client needs. The AP is also trained to take vital signs. Therefore, the appropriate activities to assign to the AP would be to deliver fresh water to clients; empty urine out of Foley bags; and take temperatures, pulses, respirations, and blood pressures. Although the AP is trained in performing cardiopulmonary resuscitation, the AP is not trained to check a crash cart, and this activity must be assigned to a licensed nurse. Any activities related to medications and IV therapy must be delegated to a licensed nurse.

The nurse would determine that which principles are a priority when implementing sterile technique? Select all that apply. 1. The edge of a sterile field and 1 inch inward are unsterile 2. If a package is not labeled as sterile, it should be considered an unsterile item 3. Sterile objects that come in contact with unsterile objects are considered contaminated 4. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched 5. When a sterile field becomes wet, it remains sterile as long as the items on the field are not contaminated 6. Items in a sterile package must be used as soon as the package is opened; otherwise, the items are considered contaminated

1, 2, 3, 6 Rationale: Sterile means the absence of all microorganisms. To maintain sterile technique, the nurse must follow several principles, including the edge of a sterile field, and 1 inch inward is unsterile; sterile packages are labeled as sterile; and if the package is not so labeled, it is considered unsterile; sterile objects that come in contact with unsterile objects are considered contaminated; items in a sterile package must be used as soon as the package has been opened, or they are considered contaminated; any part of a sterile field that falls or hangs below the top of the table is unsterile; and a sterile field that becomes wet will draw microorganisms from the surface underneath (strike-through) and contaminate the field.

The nurse is assessing a client with a history of angina who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medication? Select all that apply. 1. Dizziness 2. Bradycardia 3. Chest pain 4. Reflex tachycardia 5. Sexual dysfunction 6. Cardiac dysrhythmias

1, 2, 5 Rationale: Beta-adrenergic blockers, commonly called beta blockers, are useful in treating cardiac dysrhythmias, mild hypertension, mild tachycardia, and angina pectoris. Side effects commonly associated with beta blockers are usually dose related and include dizziness (hypotensive effect), bradycardia, hypotension, and sexual dysfunction (impotence). Options 3, 4, and 6 are reasons for prescribing a beta blocker; however, these are general side effects of alpha-adrenergic blockers.

A registered nurse is delegating activities to the nursing staff. Which activities can be safely assigned to the assistive personnel (AP)? Select all that apply. 1. Collecting a urine specimen from a client 2. Obtaining frequent oral temperatures on a client 3. Assessing's client who returned from the recovery room 6 hours ago 4. Assisting a post-cardiac catheterization client who needs to lie flat to eat lunch 5. Accompanying a client being discharged to meet his spouse at the hospital exit door

1, 2, 5 Rationale: Work that is delegated to others must be consistent with the individual's level of expertise and licensure, if any. Options 1, 2, and 5 do not include situations that indicate that these activities carry foreseeable risk. The least appropriate activities for the AP would be assessing a client and assisting the post-cardiac catheterization client. The AP is not trained or educated to safely and accurately perform an assessment on a client. Because the post-cardiac catheterization client needs to eat while lying flat, the client is at risk for aspiration.

The nurse manager is reviewing infection control interventions with the nursing staff and would include which interventions to reduce reservoirs of infection? Select all that apply. 1. Keeping bedside table surfaces clean and dry 2. Changing dressings that become wet or soiled 3. Placing tissues and soiled dressings in paper bags 4. Placing capped needles and syringes in puncture-resistant containers 5. Using soap and water to remove drainage, dried secretions, or excess perspiration from the client's skin 6. Emptying Foley catheter drainage bags on each shift, unless otherwise prescribed by a primary health care provider

1, 2, 5, 6 Rationale: Infection control measures to reduce reservoirs of infection include keeping bedside table surfaces clean and dry; changing dressings that become wet or soiled; placing tissues, soiled dressings, or soiled linens in moisture-resistant bags (not paper bags); placing syringes and uncapped needles in puncture-resistant containers; using soap and water to remove drainage, dried secretions, or excess perspiration from the client's skin; and emptying urinary drainage systems on each shift, unless otherwise prescribed by a primary health care provider.

A nurse is caring for a client prescribed furosemide. What assessment is needed to evaluate the effectiveness of therapy? 1. Pulse 2. Weight 3. Potassium level 4. Level of consciousness

2 Rationale: All diuretic medications increase urinary output, thus reducing body weight. The pulse may be affected because of decreased circulating volume, nut this is not an expected outcome of diuretic therapy. Potassium levels are monitored with some diuretics, but this is for the purpose of monitoring for side effects, not effectiveness of therapy. Option 4 is unrelated to this medication.

The nurse is planning care for a client with a prescription for an anticoagulant agent as part of treatment for deep vein thrombosis. Which would the nurse identify as a potential concern for this client? 1. Fatigue 2. Bruising 3. Infection 4. Dehydration

2 Rationale: Anticoagulant therapy predisposes the client to injury because of the agent's inhibitory effects on the body's normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of the activities of daily living and with other activities. Options 1, 3, and 4 are unrelated to this form of therapy.

A postpartum client recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. What action would the nurse encourage the client to avoid? 1. Brushing her teeth 2. Taking acetylsalicylic acid (aspirin) 3. Walking long distances and climbing stairs 4. All activities because bruising injuries can occur

2 Rationale: Aspirin is an antiplatelet medication and can interact with the anticoagulant medication and increase the clotting time beyond therapeutic ranges, so avoiding aspirin is a priority. The client does not need to avoid brushing her teeth, but she should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.

The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical purse (LPN) and an assistive personnel (AP). Based on licensure, which client is most appropriate to assign to the LPN? 1. A client diagnosed with dementia 2. A 1-day postoperative mastectomy client 3. A client who requires some assistance with bathing 4. A client who requires some assistance with ambulation

2 Rationale: Assignment of tasks must be implemented based on the job description of the LPN and AP, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The AP has the skills care for a client requiring noninvasive care such as a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.

A client has been taking fosinopril for 2 months. The nurse determines that the client is having the intended effect of therapy if the nurse notes which finding? 1. Lowered pulse rate 2. Lowered blood pressure 3. Increased monocyte count 4. Increased white blood cell count

2 Rationale: Fosinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure. It can cause tachycardia as a side effect of therapy, making a decrease in heart rate incorrect. Other side effects of the medication are neutropenia and agranulocytosis, making the remaining options incorrect.

A client receiving intravenous heparin therapy would be assessed frequently for which sign of a complication of this therapy? 1. Infection 2. Petechiae 3. Constipation 4. Decreased urine output

2 Rationale: Heparin is an anticoagulant that decreases clotting time. The nurse monitors the client for signs for bleeding, such as petechiae, bleeding gums, hematoma formation, and blood in the stool and urine. Infection, constipation, and decreased urine output are not related to heparin therapy.

Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, would the nurse monitor the client for? 1. Tinnitus 2. Ecchymoses 3. Increased pulse rate 4. Decreased blood pressure

2 Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and bodily fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.

A client who is receiving intravenous (IV) antibiotic tells the nurse, " The medication burns; I want the IV stopped." The nurse tells the client that the medication is necessary and administers the next dose. The nurse's action places the nurse at risk of which legal charge? 1. Assault 2. Battery 3. Negligence 4. Invasion of privacy

2 Rationale: In this situation, the nurse can be charged with battery because the nurse administers a medication that the client has refused. An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual's private affairs are unreasonably intruded upon.

Which client would the nurse delegate to the assistive personnel (AP)? 1. A client who needs teaching regarding the use of an incentive spirometer 2. A client who needs to have a urine specimen collected for a clean catch urine 3. A client who needs reinforcement of a dressing covering an abdominal incision 4. A client who needs assessment of a newly identified area of pressure over the right hip

2 Rationale: The AP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.

The nurse is analyzing the laboratory report for the client receiving warfarin sodium. The nurse notes that the International Normalized Ratio (INR) is 4.0. Which priority action would the nurse include in the plan of care based on this datum? 1. Auscultate the lungs 2. Monitor for epistaxis 3. Assess for pedal edema 4. Assess the skin for rashes

2 Rationale: The client receiving warfarin sodium will have regular blood testing done to monitor the prothrombin time (PT) and INR in order to determine therapeutic range. The normal INR is 0.8 to 1.2; the client receiving this medication is considered to be within the therapeutic range if they are 2 to 3 times the normal value. The client who has an INR of 4.0 is above the therapeutic range and is at risk for bleeding. Epistaxis is the only datum in this question that is indicative of bleeding.

A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure? 1. Ensure that the client is appropriately dressed 2. Administer an opioid analgesic 30 to 60 minutes before therapy 3. Schedule the therapy at a time when the client generally takes a nap 4. Assign an assistive personnel (AP) to stay with the client during the procedure

2 Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.

The nurse needs to remove a gown, mask, and gloves before exiting the room. Which action by the nurse could lead to the spread of infection? 1. Takes the gloves off first, before removing the gown first 2. While removing the gown, rolls it with the outside out 3. Washes hands after the entire procedure has been completed 4. Uses the ungloved hand to untie the neckties to remove the gown

2 Rationale: The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other area. Gloves are considered the dirtiest item and, therefore, must be removed first. Hands should be washed after removing the equipment to remove any unwanted germs still present. Ungloved hands should be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.

A client who is being treated for acute heart failure has the following vital signs: BP 85/50 mmHg; pulse 96 beats/min; respirations 26 breaths/min. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs would the nurse expect? 1. BP 85/50 mmHg, pulse 60 bpm, respirations 26 breaths/min 2. BP 98/60 mmHg, pulse 80 bpm, respirations 24 breaths/min 3. BP 130/70 mmHg, pulse 104 bpm, respirations 20 breaths/min 4. BP 110/40 mmHg, pulse 110 bpm, respirations 20 breaths/min

2 Rationale: The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. Options 1, 3, and 4 do not reflect the physiological changes attributed to this medication.

A client diagnosed with an eye infection has been placed on contact precautions. Which is the most appropriate nursing intervention to prevent the spread of infection? 1. Restrict all visitors 2. Perform meticulous handwashing frequently 3. Wear a mask and gloves for all client contacts 4. Wear sterile gloves for all contacts with the client

2 Rationale: When the client is on contact precautions, meticulous handwashing frequently is necessary. All visitors do not need to be restricted from visiting if they are instructed in the measures to prevent infection. A mask is not necessary for contact precautions, but a mask is necessary for respiratory precautions. Sterile gloves are not required, although clean gloves should be worn.

A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. Which nursing interventions would be implemented to protect the client from infection? Select all that apply. 1. Restrict all visitors 2. Admit the client to a private room 3. Place a mask on the client if the client leaves the room 4. Use strict aseptic technique for all invasive procedures 5. Place a "See the Nurse Before Entering" sign on the door to the room 6. Remove a vase with fresh flowers in the room that was left by a previous client

2, 3, 4, 5, 6 Rationale: The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room. The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a private room on the nursing unit. The use of strict aseptic technique is necessary with all invasive procedures to prevent infection. A sign indicating "See the Nurse before Entering" should be placed on the door to the client's room, so the nurse can ensure that the neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. Not all visitors must be restricted; however, visitors need to be restricted to healthy adults and must perform strict hand-washing procedures and don a mask before entering the client's room.

Which statement by the client indicates that further teaching is necessary regarding the safe use of warfarin sodium? 1. "I won't participate in games such a football anymore" 2. "I'll use an electric shaver until the anticoagulant is discontinued" 3. "I will not take any over-the-counter medications except aspirin" 4. "I will buy a medication alert tag that indicates I'm on anticoagulants"

3 Rationale: A client who is taking anticoagulants should not ingest any over-the-counter medications of any kind. This is especially true of aspirin and/or aspirin-containing products because of their potential to cause bleeding. All the remaining options are correct client statements. Strenuous games such as contact sports that can cause bruising and skin breakdown are to be avoided. Electric shavers are less irritating to the skin than razors and less likely to cause a skin breakdown. Medication alert tags or bracelets should be worn. In addition, all clients should be taught to carry identification cards that list all of the medications currently being taken.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. Aspirin can cause bleeding after surgery 2. Aspirin can cause my ability to clot blood to be abnormal 3. I need to continue to take the aspirin until the day of surgery 4. I need to check with my healthcare provider about the need to stop aspirin before the scheduled surgery

3 Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching? 1. "I need to change positions slowly" 2. "I need to monitor my blood pressure every week" 3. "I need to use salt moderately in cooking and on foods" 4. "I need to report signs and symptoms of infection to my doctor"

3 Rationale: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor. The client taking an ACE inhibitor is instructed to avoid the use of salt. The medication needs to be taken exactly as prescribed. The client needs to change positions slowly to avoid orthostatic hypotension, monitor the blood pressure weekly, and continue with other lifestyle changes to control hypertension. The client should report fever, mouth sores, and sore throats to the primary health care provider (neutropenia).

When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" state to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats/min, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating "Data, Action, & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation

3 Rationale: Charting-by-exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu.

The nurse has completed instructions with a client diagnosed with atrial fibrillation who will be taking warfarin sodium indefinitely. Which statement by the client indicates the need for further teaching? 1. "I need to use a soft toothbrush" 2. "I need to avoid drinking alcohol while taking this medication" 3. "I can continue to take my NSAIDs as previously prescribed" 4. "I should carry identification regarding the medication being taken"

3 Rationale: Client instructions for oral anticoagulant therapy include reporting any signs/symptoms of bleeding and implementing measures to prevent bleeding, taking the medication only as prescribed and at the same time each day, avoiding other medications (including over-the-counter medications and nonsteroidal anti-inflammatory drugs [NSAIDs]) without primary health care provider approval, avoiding alcohol, notifying all caregivers about the medication, carrying a Medic-Alert bracelet or card, and adhering to the schedule for follow-up blood work.

The nurse reviews would culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions would the nurse implement for this client? 1. Enteric precautions 2. Droplet precautions 3. Contact precautions 4. Airborne precautions

3 Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.

Which intervention demonstrates the nurse's awareness of the most important infection control technique? 1. Uses gloves when giving a bed bath 2. Uses sterile gloves to provide perineal care 3. Washes hands before and after every client contact 4. Uses sterile technique for an abdominal dressing change

3 Rationale: The most important infection control measure is prevention of the spread of infection, and this is accomplished by frequent handwashing. Options 1 and 4 are correct techniques but not the most important from the options provided. Using sterile gloves for perineal care is unnecessary and costly. Clean gloves are sufficient for this procedure.

The nurse is reviewing the laboratory results for a client diagnosed with chronic heart failure (HF) who is receiving torsemide 5 mg orally daily. What value would indicate to the nurse that the client might be experiencing an adverse effect of the medication? 1. A chloride level of 98 mEq/L 2. A sodium level of 135 mEq/L 3. A potassium level of 3.1 mEq/L 4. A blood urea nitrogen (BUN) level of 15 mg/dL

3 Rationale: Torsemide is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option 3 is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L. The normal chloride level is 98 to 107 mEq/L. the normal sodium level is 135 to 145 mEq/L. The normal BUN level ranges from 10 to 20 mg/dL.

The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action would the nurse take before entering the client's room? 1. Wash the hands 2. Wash the hands and wear a gown and gloves 3. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth 4. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when coughing or sneezing

3 Rationale: Tuberculosis is highly communicable disease caused by Mycobacterium tuberculosis. The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. Option 4 is an incorrect statement because special precautions are needed.

A client is being discharged to home on warfarin sodium is provided medication instructions by the nurse. Which statement indicates that the client understands the instructions? 1. "I'll stop my medication if it makes me feel funny" 2. "Stiff joints are a common side effect of the medication" 3. "If I notice blood in my urine, I will call my doctor immediately" 4. "I will never have a problem with clots again as long as I take this medication"

3 Rationale: Warfarin sodium is an anticoagulant that is used for long-term prophylaxis for the prevention of thrombosis. Clients must receive detailed instructions regarding the signs of bleeding. Hematuria is a sign of bleeding that the client should report to the health care provider. Medication should not be stopped without health care provider approval. Stiff joints are not associated with warfarin sodium. This medication does not ensure that the client will never have a problem with clots again.

A client receiving chemotherapy to treat lung cancer has an extremely low white blood cell count and is immediately placed on neutropenic precautions that include a low-bacteria diet. Which food items is the client now allowed to consume? Select all that apply. 1. Raw celery 2. Fresh apple 3. Italian bread 4. Tossed salad 5. Baked chicken 6. Well-cooked cheeseburger

3, 5, 6 Rationale: An extremely low white blood cell count places the client at risk for infection. In the immunocompromised client, a low-bacteria diet is implemented. Italian bread, baked chicken, and a well-done cheeseburger are acceptable to consume because all products are thoroughly cooked. The client avoids eating fresh fruits and vegetables. Fresh fruits and vegetables harbor organisms and place the client at risk for infection.

A client who has been prescribed Ramipril for 3 months reports a persistent dry cough that began about 1 month ago. What would the nurse interpret is likely the cause? 1. Decreased intake of fluids 2. An upper respiratory infection 3. An early indication of heart failure 4. An expected side effect of therapy

4 Rationale: A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as Ramipril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the primary health care provider if the cough becomes very troublesome to them. The other options are not associated with the client's signs/symptoms.

The nurse is teaching a client diagnosed with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation would the nurse use to best describe the reasoning for this therapy? 1. "Because of this dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" 2. This dysrhythmia decreases the volume of blood flowing from the heart, which can lead to blood clots forming in the brain" 3. The antidysrhythmic medications you are taking cause blood clots as a side effect, so you need this medication to prevent them" 4. "Because the atria are quivering, blood flows sluggishly through them, and clots form along the heart wall, which could then loosen and travel to the lungs or brain"

4 Rationale: A severe complication of atrial fibrillation is the development of mural thrombi. The blood stagnates in the "quivering" atria because of the loss of organized atrial muscle contraction and "atrial kick." The blood that pools in the atria can then clot, which increases the risk of pulmonary and cerebral emboli. Options 1, 2, and 3 do not provide accurate descriptions of the purpose for anticoagulant therapy.

A client shares with the nurse the need for dental surgery, but the client's dentist does not feel comfortable doing the surgery because the client takes acetylsalicylic acid every day. Which response would the nurse make to the client? 1. "You should probably change dentists" 2. "That's a question for you pharmacist" 3. "There's no risk to having a minor surgery while taking your aspirin" 4. "The surgery can safely be done 7 to 10 days after the medication is stopped"

4 Rationale: Acetylsalicylic acid is a antiplatelet and affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy should be stopped approximately 10 days before surgery to prevent bleeding complications. Options 1 and 2 are inappropriate responses and place the client's concern on hold. Option 3 is an incorrect response.

The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When would the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness? 1. During dialysis 2. Just before dialysis 3. The day after dialysis 4. Upon return from dialysis

4 Rationale: Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume medication. This would lead to ineffective control of the blood pressure.

A hospitalized client has been prescribed captopril. Which action, specific to this medication, would the nurse ensure that the client performs? 1. Drinks plenty of water 2. Eats food that are high in potassium 3. Consumes sufficient amounts of high-fiber foods 4. Moves from a sitting to a standing position slowly

4 Rationale: Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Orthostatic hypotension is a concern for clients taking antihypertensive medications. Clients are advised to avoid standing in one position for a long time, to change positions slowly, and to avoid extreme warmth (showers, baths, and weather). Clients are also taught to recognize the symptoms of orthostatic hypotension, including dizziness, light-headedness, weakness, and syncope. The remaining options are not specific to this medication.

A client diagnosed with hypertension has been taking a prescribed calcium channel blocker for approximately 2 months. The home care nurse monitoring the effects of therapy would determine that drug tolerance has developed if which is noted in the client? 1. Decrease in weight 2. Increased joint pain 3. Output greater than intake 4. Gradual rise in blood pressure

4 Rationale: Drug tolerance can develop in a client taking an antihypertensive such as a calcium channel blocker, which is evident by rising blood pressure levels. The primary health care provider should be notified, who may then increase the medication dosage, change medication, or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. This would also warrant adding a diuretic to the course of therapy. Joint pain is not associated with this form of tolerance.

The nurse is giving medication instructions to a client who is receiving furosemide. Which client statement indicates the need for further teaching? 1. "I need to change positions slowly" 2. I need to be careful to not get overheated in warm weather" 3. "I need to talk to my primary health care provider about the use of alcohol" 4. "I need to avoid the use of salt substitutes because they contain potassium"

4 Rationale: Furosemide is a potassium-losing diuretic, so there is no need to avoid high-potassium products, such as a salt substitute. Orthostatic hypotension is a risk, and the client must use caution when changing positions and with exposure to warm weather. The client needs to discuss the use of alcohol with the primary health care provider.

The nurse performing an admission assessment notes that the client diagnosed with gastroesophageal reflux disease (GERD) has been prescribed metoclopramide for a prolonged period. The nurse would immediately call the primary health care provider if which signs/symptoms were then noted by the nurse? 1. Dry mouth 2. Anxiety or irritability 3. Excessive drowsiness 4. Uncontrolled rhythmic movements of the face or limbs

4 Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should call the primary health care provider because these adverse effects may be irreversible, The medication would be discontinued, and no further doses should be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.

The client with atrial fibrillation is prescribed sotalol AF. Which assessment finding indicates that the client is experiencing an adverse effect of the medication? 1. Dry mouth 2. Diaphoresis 3. Difficulty swallowing 4. Dizziness and feeling faint

4 Rationale: Sotalol AF is a beta-adrenergic blocking agent that may be prescribed to treat atrial fibrillation or atrial flutter. Adverse effects include headache with chest pain and severe dizziness, fainting, fast or pounding heartbeats. Gastrointestinal disturbances, anxiety and nervousness, and unusual tiredness and weakness can also occur. Options 1, 2, and 3 are not adverse effects of this medication.

What assessment value would the nurse monitor to determine the effectiveness of warfarin therapy? 1. Daily weight 2. Blood pressure 3. Urinary output 4. International normalized ratio (INR)

4 Rationale: Warfarin is an anticoagulant, and the effectiveness of therapy is monitored by the INR value. None of the other options are affected by warfarin therapy.

The nurse would plan to wear this protective device when caring for hospitalized clients with which diagnosed disorders? Select all that apply (protective device: surgical mask) 1. Scabies 2. Tuberculosis 3. Hepatitis A virus 4. Pharyngeal diphtheria 5. Streptococcal pharyngitis 6. Meningococcal pneumonia

4, 5, 6 Rationale: A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection. Droplet precautions refer to precautions used for organisms that can spread through the air but are unable to remain in the air farther than 3 feet. Many respiratory viral infections such as respiratory viral influenza require the use of a standard surgical mask when caring for the client. Some other disorders requiring the use of a standard surgical mask include pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps; pneumonia, including meningococcal pneumonia; and the pneumonic plague. Scabies and hepatitis A are transmitted by direct contact with an infected person and require the use of contact precautions for protection. Tuberculosis requires the use of airborne precautions and the use of an individually fitted particulate filter mask. A standard surgical mask would not protect the nurse from Mycobacterium tuberculosis.

A nurse is teaching about the adverse effects of morphine with a client who has acute pain. Which of the following statements should the nurse include in the teaching? a. "You might notice that you see better in dim areas" b. "You should increase your fluid intake" c. "You should expect to have excessive urination" d. "You might experience difficulty sleeping"

b Rationale: The nurse should inform the client that an adverse effect of morphine is constipation. Therefore, the nurse should encourage the client to increase oral fluid to promote motility of the bowel.

A nurse is planning care for a client who is postoperative and scheduled to ambulate. At which of the following times should the nurse plan to administer PO morphine to the client for peak analgesic effect during the ambulation? a. 3 to 4 hrs before ambulation b. 10 to 15 min prior to ambulation c. 60 to 90 min prior to ambulation d. Immediately before ambulation

c Rationale: The peak effect of PO morphine takes 60 to 90 minutes to occur. Medicating the client 60 to 90 minutes prior to ambulation will provide the greatest analgesic effect. At 10 to 15 minutes, the client will feel a minimal analgesic effect from the medication. Medicating the client immediately prior to ambulation will not allow enough time for any analgesic effect.

A client, prescribe furosemide, is advised to eat high-potassium foods. The nurse instructs the client that which selections will be most suitable to meet this need? Select all that apply. 1. Fresh fruits 2. Aged cheese 3. Whole grain rice 4. Cured maple ham 5. Fresh vegetables

1, 5 Rationale: Fresh fruits and vegetables are a good source of potassium. The remaining options identify foods that are either high in sodium or fat or poor in potassium.

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4^C. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client?

101.1^F Rationale: F = (C x 1.8) + 32

The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? 1. A client in skeletal traction 2. A client attached to a ventilator 3. A postoperative client preparing for discharge 4. A client admitted on the previous shift with a diagnosis of gastroenteritis

2 Rationale: Airway is always a high priority, and the nurse should assess the client attached to a ventilator first. The clients described in the remaining options have needs that would be identified as intermediate priorities.

The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply. 1. "All used dishes should be sterilized" 2. "My close contacts should be tested for TB" 3. "Soiled tissues should be disposed of properly" 4. "House isolation is required for at least 8 months" 5. "The mouth should always be covered when coughing"

2, 3, 5 Rationale: TB is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.

A client diagnosed with heart failure has been receiving furosemide 40 mg orally daily. The nurse determines that the medication is effective when which findings are noted? Select all that apply. 1. Angina 2. Orthopnea 3. Pitting pedal edema 4. S3/S4 summation gallop 5. Clear sounds to bilateral lungs 6. Weight loss of 3 pounds over 24 hours

5, 6 Rationale: Furosemide is a loop diuretic used in the treatment of heart failure. Effective medication findings would include clear lung sounds and weight loss of 3 pounds over 24 hours. Signs of decreased cardiac output caused by fluid overload include angina, orthopnea, weakness, pitting pedal edema, dyspnea, and S3/S4 summation gallop.

A nurse caring for a client who receives gastrostomy tube feedings and insulin. The client us scheduled to receive a tube feeding at 0700. At which of the following times should the nurse plan to administer insulin lispro subcutaneously? a. 0600 b. 0630 c. 0645 d. 0730

c Rationale: Lispro is a rapid-acting insulin with an onset of 15 minutes. The nurse should administer the insulin dose 15 min prior to the tube feeding.

A nurse is admitting a client to the hospital following acetaminophen toxicity. Which of the following medications should the nurse expect to administer to this client? a. Acetylcysteine b. Pegfilgrastim c. Misoprostol d. Naltrexone

a Rationale: Administer acetylcysteine, which is the antidote for acetaminophen. Pegfilgrastim is used to increase the body's production of neutrophils. To prevent the formation of gastric ulcers, administer misoprostol, which is a prostaglandin hormone. To prevent alcohol craving, administer naltrexone, which is an opioid antagonist.

A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication? a. Urinary retention b. Tachypnea c. Hypertension d. Irritating cough

a Rationale: Monitor for urinary retention because morphine can suppress awareness that the bladder is full. Monitor for respiratory depression because the activation of mu receptors has an effect on respirations. Monitor for hypotension because opioid medications can lower blood pressure by dilating peripheral arterioles and veins. Administer an opioid medication to suppress a cough because opioid receptors affect the medulla.

A nurse is reviewing the laboratory values of a client who is receiving continuous IV heparin infusion and has an aPTT of 90 sec. Which of the following actions would the nurse prepare to take? a. Administer vitamin K b. Reduce the infusion rate c. Give the client a low-dose aspirin d. Request an INR

b Rationale: An aPTT of 90 seconds is outside the expected reference range of 60 to 80 seconds, which can cause anticoagulation. The nurse should contact the provider, reduce the infusion rate, and assess the client for bleeding. Vitamin K is used to reverse the effects of warfarin. It is not given to a client who is receiving heparin. Aspirin can inhibit platelet aggregation and is contraindicated for a client who is receiving heparin. An INR is indicated for a client who is receiving warfarin, but it is not indicated for a client who is receiving heparin.

A nurse is caring for a patient who has a new prescription for captopril for hypertension. The nurse should monitor the client for which of the following as an adverse effect of this medication? a. Hypokalemia b. Hypernatremia c. Neutropenia d. Bradycardia

c Rationale: Neutropenia is a serious adverse effect that can occur in clients taking an ACE inhibitor. Monitor the client's CBC and teach the client to report indications of infection to the provider. Options a, b, and d are not adverse effects of ACE inhibitors.

A nurse is caring for a client who is receiving heparin by continuous IV infusion. The client begins to vomit blood. After the heparin has been stopped, which of the following medications should the nurse administer? a. Vitamin K b. Atropine c. Protamine d. Calcium gluconate

c Rationale: Protamine reverses the anticoagulant effect of heparin. Vitamin K is used to reverse the effect of warfarin. Atropine is used to reverse bradycardia caused by beta-adrenergic blockers. Calcium gluconate is used to treat magnesium sulfate toxicity.

A nurse is taking a history for a client who reports taking aspirin about four times daily for a sprained wrist. Which of the following prescribed medications taken by the client is contraindicated with aspirin? a. Digoxin b. Metformin c. Warfarin d. Nitroglycerin

c Rationale: The effect of warfarin and other anticoagulants is increased by aspirin, which inhibits platelet aggregation. This client would have an increased risk for bleeding. Use of aspirin generally is contraindicated for clients who take warfarin. Options a, b, and d do not interact with aspirin and therefore are not contraindicated.

A nurse is caring for a client who takes warfarin 2.5 mg PO daily and has an INR of 6.2. The nurse should anticipate a prescription from the provider for which of the following medications? a. Protamine sulfate b. Fondaparinux c. Vitamin K d. Bivalirudin

c Rationale: The nurse should anticipate the provider to prescribe vitamin K antagonizes warfarin's actions, which can reverse warfarin-included inhibition of clotting factor synthesis.

A nurse is preparing to administer warfarin to a client who has a new onset of atrial fibrillation. A client asks the nurse, "What should this medication do?" Which of the following responses should the nurse make? a. "It helps your heart return to normal rhythm" b. "It dissolves blood clots" c. "It can reduce your risk of having a stroke" d. "It helps to prevent bleeding in atrial fibrillation"

c Rationale: The nurse should identify that atrial fibrillation increases the client's risk of having a stroke due to clot formation in the atrium. Warfarin can prevent clot formation when used long-term, which will reduce the client's risk of having a stroke.

A nurse in an emergency department is performing an admission assessment for a client who has severe aspirin toxicity. Which of the following findings should the nurse expect? a. Body temperature 35^C (95^F) b. Lung crackles c. Cool, dry skin d. Respiratory depression

d Rationale: Respiratory depression due to increasing respiratory acidosis is an expected manifestation of severe aspirin toxicity. Expect hyperthermia, dehydration, and diaphoresis as manifestations of severe aspirin toxicity, not the other options.

A nurse is assessing a client who is receiving a continuous morphine IV infusion and find the client's respiratory rate has decreased from 20/min to 12/min. Which of the following actions should the nurse take? a. Flush the IV line with saline b. Administer flumazenil c. Lower the head of the bed d. Slow the rate of the infusion

d Rationale: The nurse should decrease the infusion rate to reduce the amount of morphine the client receives and limit the risk of respiratory depression. Flushing the client's IV line with saline will cause the client to receive a bolus of morphine and might further reduce the client's respiratory rate. The nurse should administer flumazenil to treat benzodiazepine toxicity. Naloxone is administered to treat opioid toxicity. Lowering the head of the client's bed could decrease the client's chest expansion and impair ventilation.