Fundamentals

1 (Rationale:The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to a stretcher or wheelchair. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand.)

A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client? 1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils

2 (Rationale:Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counseling—specifically, the limitation of saturated and other fats in the diet. Beef contains fat, and its consumption should be limited)

A client has been given a prescription for gemfibrozil. The nurse should instruct the client to limit which food while taking this medication? 1.Fish 2.Beef 3.Spicy foods 4.Citrus products

1 (Rationale:The client is choking on his secretions, which should be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing his airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.)

A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? 1.Suction the client through the endotracheal tube. 2.Instruct the client in the use of an incentive spirometer. 3.Turn the client from a 30-degree lateral position to a supine position. 4.Instruct the client to use a communication board to tell the nurse what is wrong.

4 (Rationale:Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 6 to 12 hours. The client may turn from side to side. The head of the bed is not elevated more than 15 degrees (unless otherwise prescribed) to prevent kinking of the blood vessel at the groin and possible arterial occlusion.)

A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client? 1.Knee chest, with the foot of the bed elevated 2.Supine, with the head of the bed elevated 45 to 90 degrees 3.Semi Fowler's, with the knees placed on top of 1 pillow 4.Supine, with the head of the bed elevated about 15 degrees

2 (Rationale:The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours postoverdose, however, the compensatory mechanism fails, and the client reverts to metabolic acidosis.)

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms indicating the acid-base disturbance that could occur in the client? 1.Bradypnea, dizziness, and paresthesias 2.Headache, nausea, vomiting, and diarrhea 3.Bradycardia, listlessness, and hyperactivity 4.Restlessness, confusion, and a positive Trousseau's sign

1 (Rationale:The client taking tramadol should not consume alcoholic beverages while taking this medication because it further depresses the central nervous system (CNS). Cigarette smoking does not adversely affect tramadol; however, the client should be discouraged from smoking and encouraged to join a smoking-cessation program for general healthy reasons. The client may need increased calcium, but this is not because of tramadol. The client can take cough syrup with this medication.)

A client is being started on tramadol therapy for pain management after a back injury. When educating this client on tramadol therapy, what is the priority? 1.The client cannot drink alcohol while taking tramadol. 2.The client cannot smoke cigarettes while taking tramadol. 3.The client should increase the intake of calcium-rich foods. 4.The client should avoid additional over-the-counter cough syrups.

2 (Rationale:Use the medication calculation formula to determine the correct amount to administer. If the client is to receive 0.125 mg and the label on the bottle of pills states that each tablet contains 0.25 mg, the nurse would administer one half tablet.)

A client is due to receive digoxin 0.125 mg by mouth. The nurse prepares to administer the medication and notes that the label on the bottle of pills states that each tablet contains 0.25 mg. The nurse should take which action? 1.Administer 2 tablets of the medication. 2.Administer one half tablet of the medication. 3.Withhold the medication and call the health care provider (HCP). 4.Administer only 1 tablet of the medication and call the pharmacy

2 (Rationale:Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins)

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1.Milk 2.Oranges 3.Bananas 4.Chicken

4 (Rationale:Digital subtraction angiography is a radiographic method to study the blood vessels. The nurse should explain to the client that the test provides information about the blood vessels. Options 1, 2, and 3 are incorrect.)

A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective? 1."The purpose of the test is to detect lesions in the brain." 2."The purpose of the test is to inject medication into the bone." 3."The purpose of the test is to examine the cerebrospinal column." 4."The purpose of the test is to provide information about the blood vessels."

4 (Rationale:Client preparation for a myelogram includes instructing the client to withhold food and fluids for 4 to 8 hours before the procedure as prescribed. Some health care providers may allow fluids or a light diet (but not a full meal). The client is told that the procedure takes about 45 minutes. An informed consent is required, and the client will need to remove jewelry and any metal objects. The client also is told that pretest medications may be administered for relaxation.)

A client requires a myelogram, and the ambulatory care nurse is providing instructions to the client regarding preparation for the procedure. Which statement by the client indicates a need for further instruction? 1."My jewelry will need to be removed." 2."An informed consent form will need to be signed." 3."My procedure will take approximately 45 minutes." 4."I need to be sure to eat a full meal before the procedure."

4 (Rationale:The client may experience temporary hoarseness after neck dissection. Goals for the client include using nonverbal forms of communication as needed, expressing willingness to ring the call bell for assistance, and using the services of a speech pathologist if prescribed. Options 1, 2, and 3 are incorrect.)

A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem? 1.Uses nonverbal communication only 2.Describes that hoarseness will be permanent 3.Initiates communication only when necessary 4.Incorporates nonverbal forms of communication as needed

2, 4, 5, 6 (Rationale:Blood tests commonly used to confirm the diagnosis of RA include ANA, rheumatic factor, ESR, and anti-CCP. Cardiac enzymes and fasting blood glucose tests are not used to diagnose this condition. ANA is used to diagnose autoimmune diseases. An elevated ESR is used to detect inflammation of joints associated with RA. Rheumatoid factor is useful in the diagnosis of RA. Anti-CCP appears early in the course of RA and is present in the blood of most clients with the disease.)

A client with a diagnosis of question of rheumatoid arthritis (RA) is admitted to the unit. What blood tests would the nurse expect to be prescribed to confirm the diagnosis? Select all that apply. 1.Cardiac enzymes 2.Rheumatic factor 3.Fasting blood glucose 4.Antinuclear antibody (ANA) 5.Erythrocyte sedimentation rate (ESR) 6.Anticyclic citrullinated peptide antibody (anti-CCP)

1 (Rationale:Ketorolac is a nonopioid analgesic and nonsteroidal antiinflammatory agent. It acts by inhibiting prostaglandin synthesis and produces analgesia that is peripherally mediated. The nurse evaluates the effectiveness of this medication by using the pain rating scale with the client. Options 2, 3, and 4 are unrelated to the use of this medication.)

A client with a fractured femur who has had an open reduction-internal fixation is receiving ketorolac. Which assessment measurement will assist the nurse in determining the effectiveness of this medication? 1.Pain rating 2.Temperature 3.Serum calcium level 4.White blood cell count

1 (Rationale:The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.)

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1.3.2 mEq/L (3.2 mmol/L) 2.3.8 mEq/L (3.8 mmol/L) 3.4.2 mEq/L (4.2 mmol/L) 4.4.8 mEq/L (4.8 mmol/L)

3 (Rationale:The unlicensed assistive personnel (UAP) should blot the spill with an absorbent disposable material, such as paper towels or terry wipes but not with a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or an agency-approved product.)

A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel to clean up the blood spill is incorrect? 1.Uses tongs to collect any broken glass 2.Wears gloves for the cleaning procedure 3.Blots up the spill with a face cloth or cloth towel 4.Disinfects the area of the blood spill with a dilute bleach solution

3 (Rationale:Unilateral neglect is an unawareness of the paralyzed side of the body, which increases a client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment so as to become aware of the affected half of the body. The nurse approaches the client from the affected side to increase awareness further.)

A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit? 1.Telling the client to scan the environment 2.Placing the bedside articles on the affected side 3.Approaching the client from the unaffected side 4.Moving the commode and chair to the affected side

4 (Rationale:Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect.)

A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication? 1.Diaphoresis 2.Pupillary constriction 3.Increased urinary output 4.Dry oral mucous membranes

2 (Rationale:The therapeutic range for serum phenytoin level is 10 to 20 mcg/mL (39.6 to 79.2 mcmol/L). A level below the therapeutic range could place the client at risk for seizures. If a level is too high, the client is at risk for toxicity. At levels above 20 mcg/mL (79.2 mcmol/L), toxicity can occur with nystagmus, sedation, ataxia (staggering gait), diplopia (double vision), and cognitive impairment.)

An adult client with a history of seizure disorder is having a routine serum phenytoin level drawn. Which serum phenytoin result indicates that the client is having a therapeutic effect of the medication? 1.6 mcg/mL (23.8 mcmol/L) 2.16 mcg/mL (63.4 mcmol/L) 3.28 mcg/mL (110.9 mcmol/L) 4.36 mcg/mL (142.6 mcmol/L)

1 (Rationale:Cardiac MRI does not require any radiation to the client and is considered an extremely safe procedure. It does not involve any ionizing radiation and is a noninvasive, not minimally invasive, imaging technique. It also provides images in multiple planes with uniformly good resolution and not just in 1 to 2 planes.)

Cardiac magnetic resonance imaging (MRI) is prescribed for a client. When providing teaching, what does the nurse include as one of the major advantages of this test? 1.It doesn't require any radiation. 2.It provides images in 1 to 2 planes. 3.It involves low-dose administered iodine. 4.It is a minimally invasive imaging technique.

1 (Rationale:The first step is to determine the total number of mg the client will receive based on the prescribed dose of 25 mg given 4 times daily (every 6 hours). Step 1: 25 mg × 4 = 100 mgThe next step is to calculate the number of mg/kg based on the client's weight of 25 kg. Step 2: 5 mg × 25 kg = 125 mgThe final step is to compare the prescribed dose to the safe dosage range.)

Diphenhydramine hydrochloride, 25 mg orally every 6 hours, is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. The nurse should determine which concerning the dose prescribed? 1.The dose prescribed is safe. 2.The dose prescribed is too low. 3.The dose prescribed is too high. 4.There is not enough information to determine the safe dose

2 (Rationale:Ice is applied to the affected joint for pain and swelling, and analgesics are administered as prescribed. The application of heat may cause swelling and discomfort. After arthroscopy the client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return for suture removal in about 7 days.)

The ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction? 1."I should elevate my knee while sitting." 2."I can apply heat to the site if it becomes uncomfortable." 3."I should avoid excessive use of the joint for several days." 4."I should return to the health care provider for suture removal in about 7 days."

4 (Rationale:By definition, a clear liquid diet offers foods that are liquid at body temperature. Sodium intake is occasionally restricted if the client is on strict sodium regulation; however, because of the short-term nature of a clear liquid diet for the postoperative client and the limited nutritional content of the diet, electrolytes and minerals generally are lacking. To offer the client some variety and stimulate taste buds, foods of different temperatures should be offered on a clear liquid diet, ranging from frozen (e.g., Popsicles) to warm (e.g., tea). Also, clear liquid diets prohibit milk of any nature because it is not a clear liquid.)

The health care provider has prescribed a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the tray to be sure that which has occurred? 1.Sodium foods are restricted. 2.At least 1 serving of low-fat milk is served. 3.All food items are lukewarm in temperature. 4.All food items are liquid at body temperature.

3 (Rationale:A diet high in fat may be a factor in the development of certain types of cancers. High-fiber diets may reduce the risk of colon cancer. Excessive tobacco use, although not a factor in this client, may increase the risk of cancer of the lung, larynx, throat, esophagus, and bladder.)

The home care nurse is conducting a diet history with an older client who lives alone. The nurse finds that the client's typical 24-hour food intake consists of eggs and sausage for breakfast, a fast-food lunch of hamburger and french fries, takeout fried chicken for dinner, and ice cream in the evening. To decrease the risk of cancer, what statement would the nurse make to the client? 1."You should not eat eggs." 2."You should not eat sausage." 3."A high-fat diet increases your risk for colon cancer." 4."Excessive tobacco use increases the risk of liver cancer."

1 (Rationale:It is not uncommon for a client to have difficulty swallowing after experiencing a stroke. Often the client has hemiplegia. The arm on the affected side may be paralyzed, and the client may have to learn to use the opposite arm for self-feeding. Using the nondominant arm may require rehabilitation and retraining. Also, a client may have partial paralysis of the mouth, tongue, or esophagus. To best assist the client, the nurse should first assess the situation by watching the self-feeding process. Perhaps the problem lies in the feeding technique, the type of feeding tool used, the types of foods being served, or a combination. Having someone else feed the client may be necessary if self-feeding is not possible. This approach, however, does not promote independence for the client. A feeding syringe is not recommended for feeding most clients)

The home care nurse is visiting a male client who is recovering at home after suffering a brain attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself and difficulty with swallowing food and fluids. Which would be the initial nursing action? 1.Observe the client feeding himself. 2.Observe the wife feeding the client. 3.Arrange for a home health aide to assist at mealtimes. 4.Instruct the wife in the use of a feeding syringe to feed the client.

2 (Rationale:Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. It is a period during which the mood is predominantly elevated, expansive, or irritable. All options reflect the client's possible symptomatology. Option 2, however, clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.)

The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention? 1.Outlandish behaviors and inappropriate dress 2.Nonstop physical activity and poor nutritional intake 3.Grandiose delusions of being a royal descendent of King Arthur 4.Constant, incessant talking that includes sexual innuendoes and teasing the staff

1 (Rationale:A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.)

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1.Weight loss and poor skin turgor 2.Lung congestion and increased heart rate 3.Decreased hematocrit and increased urine output 4.Increased respirations and increased blood pressure

2 (Rationale:The normal therapeutic range for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A value of 0.6 ng/mL (0.76 nmol/L) falls within the therapeutic range, and the medication would be continued as at home. A values of 0.1 (0.13 nmol/L) is lower than the therapeutic range and would require additional medication to be given. A value of 1.8 ng/mL (2.30 nmol/L) and 2.4 ng/mL (3.07 nmol/L) exceeds the therapeutic range, could be toxic to the client, and would be held.)

The nurse checks the laboratory results of a serum medication level assay for a newly admitted client taking digoxin 0.125 mg orally daily. Which value would indicate a therapeutic level? 1. 0.1 ng/mL (0.13 nmol/L) 2. 0.6 ng/mL (0.76 nmol/L) 3. 1.8 ng/mL (2.30 nmol/L) 4. 2.4 ng/mL (3.07 nmol/L)

2 (Rationale:Acculturation is a process of learning a different culture to adapt to a new or changing environment. Options 1 and 3 describe a subculture. Option 4 describes ethnic identity)

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response? 1."A group of individuals identifying as a part of the Iroquois tribe among Native Americans." 2."A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." 3."A group of individuals living in the Azores that identify autonomously but are a part of the larger population of Portugal." 4."A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his or her cultural group."

4 (Rationale:For indium imaging, a sample of the client's blood is collected, and the leukocytes (white blood cells) are tagged with indium. The leukocytes are then reinjected into the client. They accumulate in infected areas of bone and can be detected with scanning. No special preparation or aftercare is necessary)

The nurse explaining the procedure of indium imaging to a client with a bone infection should include which information? 1.Indium is injected into the bloodstream and collects in normal bone but not in infected areas. 2.Indium is injected into the bloodstream and outlines the extent of the blood supply to the bone. 3.Some of the client's red blood cells are tagged with indium, which will later accumulate in normal bone. 4.Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone.

1 (Rationale:Although each of the actions in the options is important, evaluation of tube placement is the priority to prevent aspiration and to ensure that medication delivery will be in the stomach.)

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action? 1.Assess tube placement. 2.Flush with 30 mL of sterile saline. 3.Aspirate to determine residual volume. 4.Administer the antacid by gravity flow.

2 (Rationale:The NG tube should remain in place until the client has bowel sounds. If NG suction is being used, the nurse should turn off the suction before listening to bowel sounds to prevent mistaking the sound of the suction for bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative.)

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? 1.The client is drowsy. 2.Bowel sounds are absent. 3.The abdomen is slightly distended. 4.NG tube drainage is Hematest negative

3 (Rationale:Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk for these conditions. Options 1, 2, and 4 are incorrect.)

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? 1.Dilates the major bronchi 2.Increases surfactant production 3.Maintains inflation of the alveoli 4.Enhances ciliary action in the tracheobronchial tree

1 (Rationale:After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.)

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1.Reassess the client. 2.Conduct a staff meeting to describe the fall. 3.Document in the nurse's notes that an incident report was completed. 4.Contact the nursing supervisor to update information regarding the fall.

3 (Rationale:To determine each client's nutritional status and needs, the first priority of the nurse is to identify each client's food preferences. Cultural background and knowledge about nutrition are important factors influencing food choices and nutritional status. Although the remaining options may be a component of the sessions, the correct option is the first priority.)

The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority? 1.Discuss the costs of food items. 2.Review the MyPlate food guide. 3.Identify the food preferences and methods of food preparation for each client. 4.Weigh each client and ask the client to document the weight on a progress chart.

3 (Rationale:Following a tube feeding, the head of the bed should be elevated for 30 to 60 minutes to prevent vomiting and aspiration, a complication of a tube feeding. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat supine position should be avoided after a tube feeding.)

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding? 1.Supine 2.Flat on the left side 3.Fowler's on the right side 4.Semi Fowler's on the left side

1, 2, 4, 5 (Rationale:The initial radiology films to detect ascites are plain films, scout films, flat plate of the abdomen, and KUB. They are all the same type of abdominal exam but with different names. These films provide a baseline assessment of the abdomen and are done before any studies requiring a contrast medium. The other films involve the use of barium and might be done as follow-up if the initial film was inconclusive.)

The nurse is admitting a client with suspected ascites. What radiology films would initially be prescribed to diagnose ascites? Select all that apply 1.Plain film 2.Scout film 3.Small bowel series 4.Flat plate of the abdomen 5.Kidney ureters bladder (KUB) 6.Upper gastrointestinal (GI) series

3 (Rationale:A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease.)

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? 1.Pacemaker 2.Osteoporosis 3.Alcohol abuse 4.Peptic ulcer disease

4 (Rationale:Following a liver biopsy, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours. This helps to immobilize the area and provides pressure to minimize bleeding in this vascular organ. The other options are incorrect.)

The nurse is assisting the health care provider with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which position? 1.Left side-lying, with the right arm elevated above the head 2.Right side-lying, with the left arm elevated above the head 3.Left side-lying, with a small pillow or towel under the puncture site 4.Right side-lying, with a small pillow or towel under the puncture site

2 (Rationale:Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the health care provider's (HCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided to prevent displacement of the prosthesis.)

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1.Side-lying on the operative side 2.On the nonoperative side with the legs abducted 3.Side-lying with the affected leg internally rotated 4.Side-lying with the affected leg externally rotated

1 (Rationale:Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin)

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate? 1.Naloxone 2.Promethazine 3.Atropine sulfate 4.Protamine sulfate

1 (Rationale:Because preoperative medications cause sedation, the client should not be allowed to leave the bed or stretcher after the medications are administered. To ensure safety, the nurse should assist the client in using a bedpan. There is no need for a Foley catheter; in addition, a Foley catheter places the client at risk for infection. Option 4 is inappropriate; if the client verbalizes a need to void, the nurse should assist in meeting this need.)

The nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need? 1.Assist the client onto a bedpan. 2.Assist the client to the bathroom. 3.Contact the health care provider and request a prescription for a Foley catheter. 4.Tell the client that preoperative medications cause the urge to void, and check the bladder for distention.

2 (Rationale:The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours post overdose, the compensatory mechanism fails, and the client reverts to metabolic acidosis. The client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Options 1 and 3 indicate respiratory acidosis and alkalosis, respectively.)

The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance? 1.Disorientation and dyspnea 2.Drowsiness, headache, and tachypnea 3.Tachypnea, dizziness, and paresthesias 4.Decreased respiratory rate and depth, cardiac irregularities

2 (Rationale:The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. A temperature of 98.8°F (37.1°C) is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.)

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? 1.An oral temperature of 98.8°F (37.1°C) 2.A urine specific gravity of 1.043 3.A urine output that is pale yellow 4.A blood pressure of 120/80 mm Hg

1, 4, 5, 6 (Rationale:Besides maintaining urinary elimination, the kidneys are also involved with helping to regulate blood pressure, assisting in regulating acid-base balance, converting vitamin D to an active form, and producing erythropoietin for red blood cell synthesis. The kidneys do not encourage immunosuppression and do not stimulate the liver to secrete enzymes.)

The nurse is caring for a client with chronic kidney disease. The nurse knows that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply. 1.Help regulate blood pressure. 2.Encourage immunosuppression. 3.Stimulate liver to secrete enzymes. 4.Assist to regulate acid-base balance. 5.Convert vitamin D to an active form. 6.Produce erythropoietin for red blood cell synthesis.

4, 5 (Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia)

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment

1 (Rationale:Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.)

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? 1.Private room or cohort client 2.Personal respiratory protection device 3.Private room with negative airflow pressure 4.Mask worn by staff when the client needs to leave the room

1 (Rationale:Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.)

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1.Respiratory acidosis from inadequate ventilation 2.Respiratory alkalosis from anxiety and hyperventilation 3.Metabolic acidosis from calcium loss due to broken bones 4.Metabolic alkalosis from taking analgesics containing base products

3 (Rationale:The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.)

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1.Client in heart failure 2.Client in acute kidney injury 3.Client with diabetes insipidus 4.Client with controlled hypertension

1, 2, 3, 4, 6 (Rationale:Besides integrating cultural practices into Western medicine, other aspects of culturally competent care include the following: increasing client safety, reducing health disparities, increasing client satisfaction, and preventing misunderstandings between the nurse and the client. Incorporating spiritual practices as appropriate to the client's culture are also important. Maintaining eye contact when having a conversation with a client is not always part of culturally competent practices.)

The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply. 1.Increasing client safety 2.Using spiritual practices 3.Reducing health disparities 4.Increasing client satisfaction 5.Maintaining eye contact when conversing with clients 6.Preventing misunderstandings between the nurse and the client

3 (Rationale:Native American diets include fried bread and mutton prepared in lard, and these dietary issues have contributed to the increased risk of gallbladder disease in this population. Alcohol abuse, vitamin D deficiency, and corn in one's diet do not cause gallbladder disease.)

The nurse is caring for a slightly intoxicated newly admitted Native American client with gallbladder disease. Based on the client's diagnosis, what dietary issue could be causing this client's problem? 1.Vitamin D deficiency 2.History of alcohol abuse 3.Fried bread and mutton prepared in lard 4.Corn as an important component of the diet

2 (Rationale:The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Placing the child supine or prone will place the child at risk for aspiration if vomiting occurs.)

The nurse is caring for an 18-month-old child who has been vomiting. Which is the most appropriate position for this child while sleeping? 1.Supine 2.Side-lying position 3.Prone with the head elevated 4.Prone with the face turned to the side

3 (Rationale:In agranulocytosis, the WBC count decreases as a result of bone marrow suppression, and the deficiency causes the affected client to become susceptible to infection. Because some antipsychotic medications, such as clozapine, can produce this adverse effect, a baseline WBC count is obtained and is evaluated periodically during therapy with this medication. Although a basophil count is a component of the WBC differential count, it does not provide adequate data to determine the presence of agranulocytosis. Levels of BUN and creatinine that are higher than normal may indicate renal disease.)

The nurse is monitoring for agranulocytosis in a client who is taking clozapine. The nurse should check which serum laboratory result to determine the presence of agranulocytosis? 1.Basophil count lower than normal 2.Creatinine level greater than normal 3.White blood cell (WBC) count lower than normal 4.Blood urea nitrogen (BUN) level greater than normal

3 (Rationale:Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.)

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? 1.A client with ulcerative colitis 2.A client with Cushing's syndrome 3.A client admitted 6 hours ago with a 40% burn injury 4.A client who has a history of long-term laxative abuse

3 (Rationale:Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication.)

The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? 1.Encourage early ambulation. 2.Discuss the resumption of home care and other activities with the client. 3.Review hand washing techniques and pericare procedures with the client. 4.Instruct the client in proper positioning of the newborn to facilitate breast-feeding.

1, 2, 3, 4, 6 (Rationale:The rights to administering medications include the right medication, the right client, the right dose, the right route, the right time, right documentation, the right reason for the medication, and the right response to the medication. The right staff member is not a right of medication administration)

The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply. 1.The right dose 2.The right route 3.The right time 4.The right client 5.The right staff member 6.The right documentation

2 (Rationale:Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an IM injection will lessen the chance of having an increase of bleeding into the tissue. It is not necessary to apply a pressure dressing to the IM site of injection. A ⅝-inch needle is not an appropriate size needle for an IM injection. The heparin infusion is not decreased before an injection, and the rate is not adjusted unless specifically prescribed by a health care provider (HCP).)

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? 1.Use a ⅝-inch needle for the injection. 2.Apply prolonged pressure to the IM site after the injection. 3.Apply a 4 × 4 pressure dressing at the IM site after the injection. 4.Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.

3 (Rationale:The process for administration of medications via PEG tube includes checking for bowel sounds, residual, and placement prior to medication administration. Then the nurse should crush each medication and mix with tap water, administering the medications one at a time followed by a flush in between each medication. Enteric-coated tablets, sustained-release tablets, such as isosorbide mononitrate, and controlled-release tablets and capsules should not be crushed because their mechanism of slow release is interrupted.)

The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Which medication prescription should the nurse question? 1.Furosemide 20 mg via PEG tube daily 2.Digoxin 0.25 mg via PEG tube daily 3.Isosorbide mononitrate 30 mg via PEG tube daily 4.Acetaminophen elixir 650 mg via PEG every 4 hours as needed for temperature >101°F (>38.3°C)

4 (Rationale:The AIDS virus is transmitted through contact with oral secretions, sexual contact with infected semen or vaginal secretions, through contact with infected blood or blood products, from mother to fetus during childbirth, or during breast-feeding. Blood and body fluid precautions will prevent contact with infectious matter from the AIDS virus. Strict isolation is not needed and may contribute to feelings of isolation in the client. Enteric or contact precautions alone are insufficient to prevent transmission of the AIDS virus.)

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others? 1.Strict isolation 2.Enteric precautions 3.Contact precautions 4.Blood and body fluid precautions

2 (Rationale:The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.)

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1.Surgical mask and gloves 2.Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4.Surgical mask, gown, and protective eyewear

2 (Rationale:To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.)

The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen? 1.Limiting fluids 2.Having the client take 3 to 4 deep breaths 3.Asking the client to spit into the collection container 4.Asking the client to obtain the specimen after eating

1, 2, 4 (Rationale:When obtaining a droplet of blood for a blood glucose monitor, the site needs to be cleaned with an antiseptic swab and then allowed to dry completely. The puncture site should be the lateral side of the finger because the central tip contains more nerves and may be more painful. Holding the finger in a dependent position improves blood flow to the puncture site. Gentle pressure may be needed to obtain an adequate amount of blood for the test strip.)

The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply. 1.Hold the finger in a dependent position during the test. 2.Use gentle pressure to obtain an adequate amount of blood. 3.Obtain the blood specimen by puncturing the central tip of the finger. 4.Obtain the blood specimen by puncturing the lateral side of the finger. 5.Allow the drop of blood to form without squeezing near the puncture site. 6.Clean the site with an antiseptic swab, and then puncture the site immediately.

4 (Rationale:Green leafy vegetables are a good source of vitamin A, whereas milk is high in vitamin D content. Eggs are high in vitamin B complex, and tomatoes are high in vitamin C.)

The nurse is providing a dietary session to a group of clients about the vitamin content of various foods. The nurse should tell the clients that which food item is highest in vitamin A? 1.Eggs 2.Milk 3.Tomatoes 4.Green leafy vegetables

1 (Rationale:Milk provides the highest amount of vitamin D. Broccoli and oranges are high in vitamin C, and meat is high in vitamin B complex.)

The nurse is providing instructions to a client regarding food items that are high in vitamin D. The client demonstrates understanding of the instructions by stating the need to include which food item in the diet? 1.Milk 2.Meat 3.Oranges 4.Broccoli

4 (Rationale:If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes and may be reapplied after a short time. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.)

The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do? 1.Avoid the use of commercially prepared ice bags. 2.Keep the ice pack on the eye continuously for 24 hours. 3.Place the ice pack directly on the eye and cover with gauze. 4.Cover the ice pack with a pillowcase and place it on the eye.

2 (Rationale:A gallium scan is similar to a bone scan but with injection of gallium isotope instead of radioisotope. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to perform. The client needs to lie still during the procedure. There is no special aftercare.)

The nurse is providing instructions to a client who is scheduled for a gallium scan. Which statement made by the client indicates an understanding of the instructions? 1."The procedure will take all day." 2."I need to have an injection 2 to 3 hours before the procedure." 3."I will need to avoid food and fluids and remain on bed rest for 2 days after the procedure." 4."I need to get a good night's rest because I will have to stand for several hours for this test."

3 (Rationale:In Orthodox Judaism the dairy-meat combination is not acceptable. Pork and pork products also are not allowed. The only correct nursing action is to ask the dietary department to deliver a new meal tray with appropriate food choices for the client.)

The nurse notes that the client whose religion is Orthodox Judaism has received a cheeseburger with fries and skim milk as a beverage. Considering this finding, what is the best nursing action? 1.Ask the client if he likes cheeseburgers. 2.Replace the skim milk with whole milk. 3.Call the dietary department and ask for a replacement meal tray. 4.Ask the dietary department to replace the cheeseburger with a pork sausage patty.

3 (Rationale:The client will need to lie in a flat position for 45 to 60 minutes. The client is informed that magnetic resonance imaging (MRI) is a painless test and that a contrast dye may or may not be used. Additionally, no dietary restrictions are necessary with MRI. The nurse informs the client that the MRI may damage items such as credit cards and watches and that jewelry and hair clips cause artifacts. These objects should be removed from the client before the test.)

The nurse is providing instructions to the client scheduled for magnetic resonance imaging. Which instruction should the nurse provide to the client? 1.Injection of a dye is necessary. 2.Food and fluids are restricted for 12 to 24 hours before the test. 3.Lying still in a flat position for 45 to 60 minutes may be necessary. 4.The test may cause some pain, and pain medication will be prescribed if pain occurs.

1 (Rationale:The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.)

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? 1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive ingestion of vitamin D

1 (Rationale:Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client.)

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1.Prednisone 2.Ferrous sulfate 3.Cyclobenzaprine 4.Conjugated estrogen

1 (Rationale:The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A level of 150 mEq/L (150 mmol/L) would indicate hypernatremia. Hypernatremia is noted in such conditions as heart failure, Cushing's disease, dehydration, diabetes insipidus, diaphoresis, diarrhea, and hypovolemia. Hyponatremia would be noted in the conditions identified in the remaining options)

The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which conditions? 1.Heart failure 2.Addison's disease 3.A severe burn injury 4.Adrenal insufficiency

3 (Rationale:The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.)

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? 1.Normal 2.Increased 3.Decreased 4.Insignificant

3, 4, 5 (Rationale:The normal sodium level for an adult client is 135 to 145 mEq/L. Some medications are known to increase sodium levels, and these medications include anabolic steroids, oral contraceptives, and nonsteroidal antiinflammatory drugs.)

The nurse is reviewing the medication list for a client seen in the health care clinic. The nurse determines that which medications will increase the sodium level? Select all that apply 1.Laxatives 2.Stool softeners 3.Anabolic steroids 4.Oral contraceptives 5.Nonsteroidal antiinflammatory drugs

1 (Rationale:The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client also should avoid unpasteurized milk and dairy products. Fruits that the client peels are safe, as are bottled beverages. The client may be taught to avoid sorbitol, but this is to diminish diarrhea and has nothing to do with food-borne infections.)

The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness? 1.Raw oysters 2.Bottled water 3.Pasteurized milk 4.Products with sorbito

3, 4, 5 (Rationale:Providing culturally competent care or education is an important aspect of nursing. Care or education must be emphatically based on the client's culture; otherwise the care or education is not specific to the client. The correct options address culturally specific and individualized care. Options 1 and 2 are not individually focused.)

The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply. 1."Educational topics are always determined by the nurse." 2."All clients view education about their health status as important." 3."The population served will determine the culturally sensitive resources to use for teaching." 4."Assessment of a client's preferred learning approach is essential to facilitate the learning process." 5."It is important to have an accurate translator when the nurse and client do not speak the same language."

1 (Rationale:All clients, regardless of age, need to be encouraged to perform at the highest level of independence possible. Independence contributes to the client's sense of control and well-being. Option 2 is incorrect because what the self-care deficit entails is not known. To assume that the client requires long-term care based on so little information would be erroneous. Options 3 and 4 are unrealistic and are closed-ended statements.)

The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client? 1.The client will function at the highest level of independence possible. 2.The client will be admitted to a long-term care facility to have activities of daily living (ADL) needs met. 3.The nursing staff will attend to all of the client's ADL needs during the hospital stay. 4.The client will complete all ADL independently within a 1-hour time frame

4 (Rationale:Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal antiinflammatory medication and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it should be used only short term and is not recommended for use in older clients)

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question? 1.Ibuprofen by oral route 2.Morphine sulfate by intravenous route 3.Tramadol hydrochloride by oral route 4.Meperidine hydrochloride by intramuscular route

4 (Rationale:Phenylketonuria is a genetic disorder that is characterized by an inability of the body to use the essential amino acid phenylalanine. The phenylalanine level is checked to screen for this disorder. Newborn screening tests are mandatory in all 50 states and are most reliable if the blood sample is taken after the infant has ingested a source of protein. The objective in diagnosing or treating phenylketonuria is to prevent cognitive impairment. Minimal or absent phenylalanine hydroxylase activity results in profound cognitive impairment if not treated early with dietary restriction of phenylalanine. The phenylketonuria test is not used to detect cardiac disease, discover the presence of cancer, or check for the presence of a genetic condition.)

The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria rescreening blood test. The nurse determines that the parent understands the need for the test when which statement is made? 1."It can detect heart disease in my baby." 2."It will discover the presence of cancer in my baby." 3."It will check for the presence of a genetic condition in my infant." 4."It will allow me to institute measures to prevent complications if the level is elevated."

2 (Rationale:A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by positive antistreptolysin O titer, Streptozyme slide tests, or anti-DNase B assays. An antistreptolysin O titer is not a specific laboratory test for the conditions identified in options 1, 3, and 4.)

The nurse reviews the health care provider's (HCP's) prescriptions for a child with a streptococcal infection. The HCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis should the nurse suspect in the child? 1.Heart failure (HF) 2.Rheumatic fever (RF) 3.Aortic valve disease (AVD) 4.Pulmonic valve disease (PVD

3 (Rationale:The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.)

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level? 1.Prominent U waves 2.Prolonged PR interval 3.Depressed ST segment 4.Widened QRS complexes

2 (Rationale:In the Asian culture, direct eye contact often is viewed as being rude. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. It is not necessary to change the assignment. Two of the other options—assuming that the client is having difficulty hearing the nurse or leaving the room and returning later to continue with the explanation—may be viewed as rude gestures by the client.)

The unlicensed assistive personnel (UAP) is assigned to care for a client who is of Asian heritage. The UAP tells the nurse, "I think that my assignment needs to be changed. Every time I try to talk, the client turns away." Which statement is the most appropriate teaching response from the nurse? 1."You are right. Your assignment needs to be changed." 2."If the client turns away, continue with the discussion." 3."If the client turns away, leave the room and return later to finish your care." 4."The client may have difficulty hearing. Speak up when talking to the client."

3 (Rationale:When the client has a Sengstaken-Blakemore tube inserted, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures, moving the esophageal balloon upward and occluding the airway. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside but is not the priority item.)

Treatment for a client with bleeding esophageal varices has been unsuccessful, and the health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action? 1.Request an obturator. 2.Obtain a Kelly clamp. 3.Place a pair of scissors at the client's bedside. 4.Pour sterile water in the irrigation set basins.

2, 3, 4 (Rationale:The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. Lead shielding can be used to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.)

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1.Limiting the time with the client to 1 hour per shift 2.Keeping pregnant women out of the client's room 3.Placing the client in a private room with a private bath 4.Wearing a lead shield when providing direct client care 5.Removing the dosimeter film badge when entering the client's room 6.Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client

4 (Rationale:When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs.)

Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? 1.Wearing protective garb when visiting the infant 2.Washing the hands before leaving the infant's room 3.Telling a family member who has asthma that he should not visit the infant 4.Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant

4 (Rationale:The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.)

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1.The client with colitis 2.The client with Cushing's syndrome 3.The client who has been overusing laxatives 4.The client who has sustained a traumatic burn

1 (Rationale:The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.)

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids