HELLA HESI

D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents."

C

D) "I cannot use floss because it may irritate my gums."

C

D) "I have trouble catching my breath."

C

D) "You will experience increased menstrual bleeding while on this drug."

C

D) 15 seconds

C

D) Abdominal percussion

C

D) Add blue dye to the feeding tube formula.

C

D) Administering naloxone (Narcan) IV push

C

D) Assess whether the client needs anti-arthritis medication.

C

D) Client who just delivered a baby

C

D) Cold and gray-blue lower extremity

C

D) Complete the nursing care plan.

C

D) Crepitus of the skin around the left lung

C

D) Dantrolene sodium (Dantrium)

C

D) Document as a stage III pressure ulcer and start antibiotic therapy.

C

D) Draw blood for albumin, prealbumin, and total protein.

C

D) Experiencing urinary frequency after catheter removal

C

D) Healthy individual, works outside the home, uses a cane, well groomed

C

D) Hold the warfarin dose until the heparin is discontinued.

C

D) Inquiring about recent travel to foreign countries

C

D) Intubate a client whose oxygen saturation is 92%.

C

D) Maintain a calm and quite environment by minimizing visitors.

C

D) Monitor the client's hematocrit and hemoglobin.

C

D) Notifying the physician of the client's increase in restlessness after medication change

C

D) O-No!!

C

D) Older adult with exercise-induced wheezing

C

D) Prevent hypoglycemia.

C

D) Raise bed side rails due to potential decreased level of consciousness and confusion.

C

D) Severely reddened skin

C

D) Sodium has risen from 130 to 144 mg/dL.

C

D) Test sensory perception in the client's hands.

C

D) The blood pressure reading is 148/94 mm Hg.

C

D) The patient will verbalize an understanding of the importance of following the regimen.

C

D) Uses sodium-containing antacids frequently

C

D) keep the head of the bed elevated 30 degrees.

C

D) "Discontinue the medication if you develop an infection."

A

D) "Do you want daily weights on this client?"

A

D) that team up north

C

D) "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin."

A

D) "I have to wear a mask at all times."

A

D) "I will continue my diabetic diet and restrict sugar."

A

D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."

A

D) "Maybe. Let's look at your risks for cardiovascular disease."

A

D) "Rotate your insulin injection sites."

A

D) "When getting out of bed in the morning, I will sit for a few moments then stand."

A

D) 3.8 mEq/L

A

D) 8 PM

A

D) Absence of confusion

A

D) Apply talcum powder to the perineal area.

A

D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge

A

D) Gabapentin (Neurontin)

A

D) Heat intolerance

A

D) Hemoglobin, 14.2 g/dL

A

D) Measure the reddened area on the skin surface.

A

D) Middle-aged man with pulmonary hypertension

A

D) Peripheral venous disease

A

D) Place the client in a high Fowler's position.

A

D) Place the client in isolation.

A

D) The white blood cell differential indicates a right shift.

A

D) Turn the client's plate around halfway through the meal.

A

D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the drug is given

A

D) inability to focus visually.

A

D) oral thermometer.

A

D) reservoir.

A

D) with a heart rate of 100 beats/min and blood pressure of 100/60

A

d. Measuring intake and output every four hours

A

d. anger and hostility

A

d. call the health care provider

A

d. decreased carbohydrate, protein, and fat destruction

A

d. increased total body water

A

10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

A

106. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy.

A

107. Which approach is the best way to prevent infections when providing care to clients in the home setting? A) Hand washing before and after examination of clients B) Wearing non powdered latex free gloves to examine the client C) Using a barrier between the client's furniture and the nurse's bag D) Wearing a mask with a shield during any eye/mouth/nose examination

A

109. A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance? A) Ask the child if the mouth is burning or throat pain is present B) Take the child's pulse at the wrist and see if the child is has trouble breathing lying flat. C) What color is the child's lips and nails and has the child voided today? D) Has the child had vomiting or diarrhea or stomach cramps yet?

A

112. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages

A

118. Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels."

A

127. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by accu check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities

A

136. A client diagnosed with anorexia nervosa states after lunch, "I shouldn't have eaten all of that sandwich, I don't know why I ate it, I wasn't hungry." The client's comments indicate that the client is likely experiencing A) Guilt B) Bloating C) Anxiety D) Fear

A

139. A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist B) The elders may be with the client during the process of the client dying and no last rites are given C) The family must be with the client during the process of dying and be the only ones to wash the body after death D) The body is ritually cleansed and burial is to be as soon as possible after the death Occurs

A

14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness

A

144. Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) "You look upset. Would you like to talk about it?" B) "I'd like to know more about your family. Tell me about them." C) "I understand that you lost your partner. I don't think I could go on if that happened to me." D) "You look very sad. How long have you been this way?"

A

160. The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastrostomy tube placement, the priority is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium

A

26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation

A

27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88

A

29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

A

41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes

A

49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube

A

50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion

A

51. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip

A

61. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance

A

63. The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts

A

65. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion

A

68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem

A

7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B)This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D)The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

A

74. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

A

76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

A

78. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

A

83. A client with diarrhea should avoid which of the following? A) Orange juice B) Tuna C) Eggs D) Macaroni

A

90. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity

A

94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins

A

99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens

A

which statement about a patient with a tube feeding indicates best practice for patient safety & quality care? A) if the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a 50 mL piston syringe B) when administering medications, use cold water to dissolve the drug before administering it C) use cranberry juice to flush the tube if it is clogged D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the drug is given

A

The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be: A) change in level of consciousness. B) unequal pupil size. C) loss of primitive reflexes. D) inability to focus visually.

A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm3, prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count 2000/mm3. Which action by the nurse is most appropriate? A) Request a dietary consult. B) Assess the client's vital signs. C) Document the findings. D) Place the client in isolation.

A Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The albumin and lymphocyte counts given are normal. The white blood cell count is not directly related to nutritional status. The prealbumin count is low and is a more specific indicator of nutritional status than is the albumin count. This puts the client at risk for impaired wound healing, so the nurse should request a dietary consult.

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? A) Middle-aged woman with aortic stenosis B) Older woman who smokes cigarettes daily C) Older man who has had a myocardial infarction D) Middle-aged man with pulmonary hypertension

A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

A confused client is hospitalized for possible pneumonia and is admitted from the emergency department with an indwelling catheter in place. During interdisciplinary rounds the following day, what question by the nurse takes priority? A) "Can we discontinue the in-dwelling catheter?" B) "Will the client be able to return home?" C) "Should we get another chest x-ray today?" D) "Do you want daily weights on this client?"

A An in-dwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections? A) "Even if I feel completely well, I should take the medication until it is gone." B) "When my urine no longer burns, I will no longer need to take the antibiotics." C) "If my urine becomes lighter and clearer, I can stop taking my medicine." D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."

A Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client.

The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with? A) Peripheral arterial disease B) Deep vein thrombosis C) Diabetic foot ulceration D) Peripheral venous disease

A Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by peripheral arterial disease are painful and initially are located at the most distal points on the extremity. Diabetic ulcers and venous ulcers are seldom painful and usually tend to occur where pressure is applied.

What statement indicates that the client understands teaching about neutropenia? A) "I will call my doctor if I have an increase in temperature." B) "My grandchildren may get an infection from me." C) "I need to use a soft toothbrush." D) "I have to wear a mask at all times."

A Bone marrow suppression leads to neutropenia and increases the client's risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a: A) portal of entry. B) host. C) mode of transmission. D) reservoir.

A Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

B.

A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? 1) Aphagia 2) Hoarseness 3) Tinnitus 4) Epistaxis

A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury? A) "Use a bath thermometer to test the water temperature." B) "Examine your feet daily using a mirror." C) "Wear white socks instead of colored socks." D) "Rotate your insulin injection sites."

A Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.

The nurse is assessing a client's understanding of his hypertension therapy. What client statement indicates a need for further teaching? A) "When my blood pressure is normal, I will no longer need to take medication." B) "If my blood pressure stays under control, I will reduce my risk for a heart attack." C) "If I lose weight, I might be able to reduce my blood pressure medication." D) "When getting out of bed in the morning, I will sit for a few moments then stand."

A Compliance with antihypertensive therapy is difficult for two reasons. First, often clients have no distressing symptoms associated with hypertension and may not believe that they have a problem. Second, many clients believe that once blood pressure is brought back into the normal range, they are "cured" and no longer need to take medication. Losing weight might allow the client to reduce medications. Lowering blood pressure does lower risk for heart attack. Because blood pressure medications often lead to orthostatic hypotension, clients should be taught to change position slowly, sitting first before standing after lying flat.

The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? A) Place the client in high Fowler's position. B) Verbalize the placement of food on the client's plate. C) Order a clear liquid diet for the client. D) Turn the client's plate around halfway through the meal.

A Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids.

An older adult client presents with signs and symptoms related to dig toxicity. Which age related change may have contributed to this problem? a. decreased renal blood flow b. increased gastrointestinal motility c. decreased ratio of adipose tissue to lean body mass d. increased total body water

A Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to dig toxicity.

The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestations does the nurse expect to see? A) Nystagmus & Diplopia B) Hyperresponsive reflexes C) Excessive somnolence D) Heat intolerance

A Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS.

Which statement by a patient indicates additional teaching is required about the medication warfarin? A) "I will increase the intake of green, leafy vegetables for a more healthful diet." B) "I will restrict the intake of foods high in vitamin C." C) "I will increase the amount of protein in my diet to protect my kidneys." D) "I will continue my diabetic diet and restrict sugar."

A Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the amount of vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to warfarin.

Which nursing intervention best assists a bedridden client to keep skin intact? A) Use a lift sheet to move the client in bed. B) Turn the client every 2 to 4 hours. C) Use a foam mattress pad. D) Apply talcum powder to the perineal area.

A Friction forces are generated when the client is dragged or pulled across bed linen; this often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an important intervention, but powders should not be used in the perineal area. To minimize vasoconstriction and possible pressure ulcer development from dependency, the client should be turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to an area.

A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? A) 2.9 mEq/L B) 5.0 mEq/L C) 6.0 mEq/L D) 3.8 mEq/L

A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. assess the client's respiratory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure d. call the health care provider

A In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement.

The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? A) "No. In fact, your body mass index suggests that you are already underweight." B) "Yes. Your body mass index suggests you are slightly overweight." C) "Your weight is just fine. Don't worry about it." D) "Maybe. Let's look at your risks for cardiovascular disease."

A The client's body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight.

A client with diabetes is prescribed insulin glargine once daily and regular insulin four times daily. One dose of regular insulin is scheduled at the same time as the glargine. How does the nurse instruct the client to administer the two doses of insulin? A) "Draw up and inject the insulin glargine first, then draw up and inject the regular insulin." B) "First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together." C) "First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together." D) "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin."

A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine, then the regular insulin right afterward.

Which is the highest priority goal to set for a client with pneumonia? A) Maintenance of SaO2 of 95% B) Walking 20 feet three times daily C) Absence of cyanosis D) Absence of confusion

A Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation.

The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time does the nurse assess the client for problems related to the NPH insulin? A) 4 PM B) 11 PM C) 8 AM D) 8 PM

A NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.

A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication? A) "Avoid taking nonsteroidal anti-inflammatory drugs." B) "Change positions slowly when you get up." C) "If you miss a dose of this drug, you can double the next dose." D) "Discontinue the medication if you develop an infection."

A Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

The nurse is caring for an older postoperative client. Which assessment finding causes the nurse to assess further for a wound infection? A) The client is now confused but was not confused previously. B) Moderate serosanguineous drainage is seen on the dressing. C) The white blood cell count is 8000/mm3. D) The white blood cell differential indicates a right shift.

A Older adult clients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in mental status in the older postoperative client should lead the nurse to assess for a wound infection.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction

A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response.

When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility

A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred.

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? A) Tissue plasminogen activator B) Heparin sodium C) Warfarin (Coumadin) D) Gabapentin (Neurontin)

A The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? A) Administer loop diuretics as prescribed. B) Begin cardiopulmonary resuscitation (CPR). C) Promote rest and minimize activities. D) Place the client in a high Fowler's position.

A The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? A) Erythrocyte sedimentation rate (ESR), 55 mm/hr B) Potassium, 5.5 mEq/L C) Sodium, 144 mEq/L D) Hemoglobin, 14.2 g/dL

A The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient: A) with a hemoglobin of 8.5 g/dL B) with a blood glucose of 350 mg/dL C) who has been on anticoagulants for 10 days D) with a heart rate of 100 beats/min and blood pressure of 100/60

A The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) A) rectal thermometer. B) tympanic membrane sensor. C) temporal thermometer scan. D) oral thermometer.

A The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

What interrelated constructs facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge

A The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

The nurse observes a small opening that is draining purulent material on the skin over the trochanter area of a bedridden client. Which is the nurse's next best action? A) Probe for a larger pocket of necrotic tissue. B) Apply alginate dressing daily. C) Apply a transparent film dressing. D) Measure the reddened area on the skin surface.

A This "hidden" wound may first be observed as a small opening in the skin through which purulent drainage exudes. Applying a transparent film dressing would not help this type of wound to heal. Measuring the reddened area would not assist in determining the actual size of the wound, because internal damage has occurred. Alginate dressings could not be applied if the area were not opened.

Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position d. Measuring intake and output every four hours

A Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

B Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? A) "The hospital requires that all inpatients be weighed daily." B) "Weight is the best indication that you are gaining or losing fluid." C) "You need to lose weight to decrease the incidence of heart failure." D) "Daily weights will help us make sure that you're eating properly."

D Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings should be changed when the outer layer becomes saturated.

A client has a deep wound covered with a wet-to-damp dressing. Which intervention does the nurse include on this client's care plan? A) Apply a new dressing when the seal breaks and the dressing leaks. B) Change the dressing when the current dressing is saturated. C) Leave the dressing intact until next week. D) Change the dressing every 6 hours around the clock.

C The client may have aspirated. The nurse should further assess the client's respiratory and oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful.

A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes priority? A) Auscultate bowel sounds and slow the feeding down. B) Remove the tube immediately and notify the heath care provider. C) Auscultate lung sounds and obtain oxygen saturation. D) Add blue dye to the feeding tube formula.

C Clients who are severely immune compromised or who have diabetes mellitus are more prone to fungal urinary tract infection. The nurse should assess for these factors. A physical examination and a post-void residual may be needed, but not until further information is obtained. Travel to foreign countries probably would not be as important, because even if exposed, the client needs some degree of immune compromise to develop a fungal urinary tract infection.

A client has a urinary tract infection. Which assessment by the nurse is most helpful? A) Palpating and percussing the kidneys and bladder B) Performing a bladder scan to assess post-void residual C) Assessing medical history and current medical problems D) Inquiring about recent travel to foreign countries

C A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the necrotic tissue and a possible graft to promote healing.

A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action? A) Document as a stage I pressure ulcer and apply a transparent dressing. B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments. C) Document as a stage IV pressure ulcer and prepare the client for débridement. D) Document as a stage III pressure ulcer and start antibiotic therapy.

A The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? A) Administer loop diuretics as prescribed. B) Begin cardiopulmonary resuscitation (CPR). C) Promote rest and minimize activities. D) Place the client in a high Fowler's position.

C Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium.

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, including steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain crackers

C Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.

A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? A) Restrict fluid intake. B) Prevent ketosis. C) Control hyperglycemia. D) Prevent hypoglycemia.

B All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration.

A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide? A) "Take the drug with food or milk." B) "Report any abdominal pain or dark-colored vomit." C) "Expect to experience weight gain." D) "Watch your diet while on this medication."

A, B, C, F Dehydration can accompany fever, especially if the client is sweating profusely. Blood pressure, pulse quality, and skin turgor are assessments of fluid status. Mental status changes can accompany fluid losses, especially in older clients.

A client is admitted with infection and a high fever. Which assessments by the nurse take priority? (Select all that apply.) A) Skin turgor B) Pulse quality C) Blood pressure D) Bowel sounds E) Respiratory effort F) Mental status

C The client with pneumonia may have dullness to percussion on the affected side. The other options are all inconsistent with pneumonia.

A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse correlate with this condition? A) Expiratory wheeze on the right side B) Crackles heard on expiration bilaterally C) Dullness to percussion on the lower left side D) Crepitus of the skin around the left lung

D Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? a. I will use a salt substitute when making and eating my meals. b. I must drink a quart of water or other liquid each day. c. I will not drink liquids after 6 PM so I won't have to get up at night. d. I will weigh myself each morning before I eat or drink.

B Lower urinary tract infections are rarely associated with systemic symptoms of fever and chills. A client with a UTI who develops fever and chills should be assessed for the development of pyelonephritis. The other options can be seen with UTI.

A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI? A) Hematuria B) Fever and chills C) Cloudy, dark urine D) Burning on urination

B Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she should immediately stop the infusion. Even if the IV has a good blood return, some of the chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the correct action, depending on the specific agent. However, the compress would be applied only after the infusion has been discontinued.

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site? A) Apply a cold compress. B) Discontinue the infusion. C) Slow the rate of infusion. D) Check for a blood return.

A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.

A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? A) 2.9 mEq/L B) 5.0 mEq/L C) 6.0 mEq/L D) 3.8 mEq/L

B Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia.

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the nurse prepare for this client FIRST? A) Continuous arteriovenous rewarming B) Dry clothing and warm blankets C) Peritoneal lavage with warmed normal saline D) Administration of warmed IV fluids

C A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after it has been determined drainage, odor, and other risks for infection are present. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done.

A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse implements? A) Place the client in bed and instruct him or her to elevate the foot. B) Prepare for and assist with obtaining a wound culture. C) Assess the affected leg for pulses, skin color, and temperature. D) Draw blood for albumin, prealbumin, and total protein.

C Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.

A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? A) Interferon beta-1b (Betaseron) B) Baclofen (Lioresal) C) Methylprednisolone (Medrol) D) Dantrolene sodium (Dantrium)

B Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs.

A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? A) "I am preventing the spread of infection from you to me or any other client here." B) "The clothing protects me from accidentally absorbing these drugs." C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." D) "These coverings protect you from getting an infection from me."

A The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? A) Tissue plasminogen activator B) Heparin sodium C) Warfarin (Coumadin) D) Gabapentin (Neurontin)

D Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention.

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? A) New-onset confusion B) Repeated syncope C) Abdominal distention D) Spontaneous ecchymosis

A, B, C

A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face 4) Tremors 5) Obese extremities

B The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately.

A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? A) "Rehabilitation will reverse any physical deficits caused by the stroke." B) "Rehabilitation will help you function at the highest level possible." C) "If you do not have rehabilitation, you may never walk again." D) "Your doctor knows best and has ordered this treatment for you."

A Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication? A) "Avoid taking nonsteroidal anti-inflammatory drugs." B) "Change positions slowly when you get up." C) "If you miss a dose of this drug, you can double the next dose." D) "Discontinue the medication if you develop an infection."

D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? A) "Eat six small meals daily instead of three larger meals." B) "When you feel short of breath, take an additional diuretic." C) "Avoid drinking more than 3 quarts of liquids each day." D) "Weigh yourself daily while wearing the same amount of clothing."

B.

A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1) Weigh the client weekly. 2) Irrigate the catheter as prescribed. 3) Instruct the client to report an urge to urinate. 4) Instruct the client to bear down as if to have a bowel movement every hour.

A Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The albumin and lymphocyte counts given are normal. The white blood cell count is not directly related to nutritional status. The prealbumin count is low and is a more specific indicator of nutritional status than is the albumin count. This puts the client at risk for impaired wound healing, so the nurse should request a dietary consult.

A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm3, prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count 2000/mm3. Which action by the nurse is most appropriate? A) Request a dietary consult. B) Assess the client's vital signs. C) Document the findings. D) Place the client in isolation.

B Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do? A) Participate in community activities. B) Verbalize his or her thoughts and feelings. C) Ask the client's physician for an antianxiety agent. D) Join a support group for people with COPD.

A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine, then the regular insulin right afterward.

A client with diabetes is prescribed insulin glargine once daily and regular insulin four times daily. One dose of regular insulin is scheduled at the same time as the glargine. How does the nurse instruct the client to administer the two doses of insulin? A) "Draw up and inject the insulin glargine first, then draw up and inject the regular insulin." B) "First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together." C) "First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together." D) "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin."

D Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? A) "Avoid using aspirin-containing products." B) "Take your medication with food." C) "Check your pulse daily." D) "Avoid using salt substitutes."

C.

A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function.

A An in-dwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

A confused client is hospitalized for possible pneumonia and is admitted from the emergency department with an indwelling catheter in place. During interdisciplinary rounds the following day, what question by the nurse takes priority? A) "Can we discontinue the in-dwelling catheter?" B) "Will the client be able to return home?" C) "Should we get another chest x-ray today?" D) "Do you want daily weights on this client?"

A Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.

A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury? A) "Use a bath thermometer to test the water temperature." B) "Examine your feet daily using a mirror." C) "Wear white socks instead of colored socks." D) "Rotate your insulin injection sites."

A The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? A) Erythrocyte sedimentation rate (ESR), 55 mm/hr B) Potassium, 5.5 mEq/L C) Sodium, 144 mEq/L D) Hemoglobin, 14.2 g/dL

B.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? 1) Observing for facial asymmetry 2) Checking pupillary responses to light 3) Eliciting the gag reflex 4) Testing visual acuity

C.

A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? 1) Report of urinary retention 2) Elevated blood pressure above 140/90 3) Report of dryness with vaginal intercourse 4) Elevated body temperature above 37.8° C (100° F)

A.

A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? 1) Take this medication between meals. 2) Limit intake of Vitamin C while taking this medication. 3) Take this medication with milk. 4) Limit intake of whole grains while taking this medication.

D Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a few minutes to prevent hypotension-induced falls. No indication is known for assessment of the apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg position is not indicated. In case of a precipitous drop in blood pressure, a modified Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in this situation.

A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention? A) Place the client in Trendelenburg position to facilitate blood flow to the heart. B) Take the client's apical pulse for 1 full minute before drug administration. C) Instruct the client to drink 3 L of fluid daily when taking this medication. D) Educate the client to sit on the side of the bed for a few minutes before rising.

B D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiving intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a sulfonamide antibiotic

A.

A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? 1) Abdomen is distended 2) Chest tube drainage of 70 mL in the last hour 3) Subcutaneous emphysema is noted to the left chest wall 4) Pain level of 6 on a 0 to 10 scale

B.

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? 1) Obtain vital signs. 2) Stop the transfusion. 3) Notify the registered nurse. 4) Administer diphenhydramine.

B.

A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? 1) Position the client supine while in bed. 2) Change the nasal drip pad as needed. 3) Encourage frequent brushing of teeth. 4) Encourage the client to cough every 2 hr following surgery.

D.

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Polyuria 2) Battle's sign 3) Nuchal rigidity 4) Lethargy

C.

A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? 1) Individuals at high risk should receive the live influenza vaccine. 2) Immunization for influenza should be repeated every 10 years. 3) The composition of the influenza vaccine changes yearly. 4) The influenza vaccine is necessary only for clients who have never had influenza.

A, B

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. 3) Insert a urinary catheter. 4) Elevate the client's head of bed. 5) Apply a cervical collar to the client.

B.

A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? 1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client's weights are hanging freely from the bed. 3) Check the client's bony prominences every 12 hr. 4) Cleanse the client's pin sites with povidone-iodine.

A.

A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 1) Hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia

C.

A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? 1) Inspiratory stridor 2) Expiratory wheeze 3) Absence of breath sounds 4) Coarse crackles

A.

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? 1) Fully recollapse the reservoir after emptying it. 2) Empty the reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.

D.

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? 1) Relieve the client's pain. 2) Check the client's pressure points for redness. 3) Provide oral hygiene. 4) Prevent aspiration.

D.

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? 1) Malnourishment related to NPO status and dysphagia 2) Impaired verbal communication related to the tracheostomy 3) High risk for infection related to surgical incisions 4) Ineffective airway clearance related to thick, copious secretions

A.

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? 1) Reducing anxiety 2) Increasing blood pressure 3) Increasing coughing 4) Increasing the client's respiratory rate

A.

A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? 1) Altered level of consciousness 2) Oral temperature of 37.7° C (100° C) 3) Muscle spasms 4) Headache

A.

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take? 1) Check pedal pulses every 15 min. 2) Perform passive range-of-motion for the affected extremity. 3) Remind the client not to turn from side to side. 4) Keep the client in high-Fowler's position for 6 hr.

C.

A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? A. Emesis of 100 mL B. Oral temperature of 37.5° C (99.5° F) C. Thick, red-colored urine D. Pain level of 4 on a 0 to 10 rating scale

A.

A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? 1) Denial 2) Bargaining 3) Acceptance 4) Anger

D.

A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening." 3) "Your provider scheduled this, so she will want to know you still have questions about the procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."

B.

A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you."

C.

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? 1) To provide analgesia 2) To reduce inflammation 3) To prevent blood clotting 4) To prevent fever

D.

A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? 1) Tuberculin skin test 2) Sputum culture for acid fast bacillus (AFB) 3) Bacille Calmette-Guérin (bCG) vaccine 4) Chest x-ray

A.

A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? 1) Attempt to determine what the client was looking for. 2) Explain the client's Alzheimer's diagnosis to the frightened client. 3) Reprimand the client for invading the other client's privacy. 4) Ask the client to apologize for his behavior.

A.

A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? 1) Encourage the client to drink 8 glasses of water a day. 2) Instruct the client to cough every 4 hr. 3) Provide the client with a low protein diet. 4) Advise the client to lie down after eating.

C.

A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 1) Improved speech patterns 2) Increased bladder function. 3) Decreased tremors 4) Diminished drooling

B.

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? 1) A continuous seizure state in which seizures occur in rapid succession 2) A sensory warning that a seizure is imminent 3) A period of sleepiness following the seizure during which arousal is difficult 4) A brief loss of consciousness accompanied by staring

C.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? 1) Monitor for elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head.

A.

A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? A. Shivering B. Infection C. Burns D. Hypervolemia

C

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? 1) Suggest that the client rests before eating the meal. 2) Request a dietary consult. 3) Check the client's vital signs. 4) Request an order for an antiemetic.

B.

A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first? 1) Establish IV access. 2) Feel for a carotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds.

C.

A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make? 1) "If you just sit quietly with your mother, I'm sure she will calm down." 2) "I'll talk with your mother and see if I can comfort her." 3) "It must be hard to see your mother so ill and upset." 4) "Your mother's crying seems to bother you more than it does her."

D.

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box of chocolates 4) Fresh fruit basket

A.

A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor? 1) Respiratory difficulty 2) Confusion 3) Increased intracranial pressure 4) Joint pain

A.

A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures

B.

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? 1) "I took a laxative yesterday." 2) "I took my metformin before breakfast." 3) "I haven't had anything to eat or drink since last night." 4) "The last time I voided it was painful."

B.

A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? 1) ½ cup whole-grain pasta with tomato sauce and pears 2) Turkey and cheese sandwich with scalloped potatoes 3) ½ cup black beans with a brownie 4) Roast beef with romaine lettuce salad

A, D

A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notify the provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing.

D.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent

D.

A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? 1) Hot flashes 2) Recurrent urinary tract infections 3) Blood in the stool 4) Abnormal vaginal bleeding

C.

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence of absence seizures

B.

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? 1) Review stress factors that can cause disease exacerbation. 2) Evaluate fluid and electrolyte levels. 3) Provide emotional support. 4) Promote physical mobility.

C.

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen for retroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily.

B.

A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of the following manifestations should the nurse monitor? 1) Hypernatremia 2) Hypotension 3) Bradycardia 4) Hypokalemia

C.

A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 1) Offer the client apple juice. 2) Elevate the client's head of bed. 3) Auscultate the client's abdomen. 4) Order a lunch tray for the client.

A.

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? A. Provide humidified oxygen. B. Perform chest physiotherapy prior to suctioning. C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. D. Hyperventilate the client with 100% oxygen before suctioning the airway..

B.

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediately and get the client a bedpan. 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay.

A.

A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 1) Empty the suction device every 4 hr. 2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr. 3) Position the client's hip so that it is internally rotated. 4) Encourage foot exercises every 4 hr.

C.

A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? 1) Urticaria 2) Muscle pain 3) Hypotension 4) Distended neck veins

D.

A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? 1) Advise the client to lie down after meals. 2) Instruct the client to restrict food intake prior to treatment. 3) Provide the client with an antiemetic 2 hr prior to the chemotherapy. 4) Encourage the client to drink a carbonated beverage 1 hr before meals.

C.

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? 1) Neck vein distention 2) Blood pressure 3) Body weight 4) Abdominal girth

C.

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? 1) "You shouldn't feel any pain since the local area is anesthetized." 2) "Most clients report more discomfort from the preparation than from the procedure itself." 3) "You may feel some cramping during the procedure." 4) "Don't worry; you won't remember anything about the procedure due to the effects of the medication."

B.

A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? 1) "My mouth is very dry." 2) "I feel very sleepy." 3) "I am not hungry any longer." 4) "My leg feels numb."

B.

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? 1) Prone with arms raised over the head. 2) Sitting, leaning forward over the bedside table. 3) High Fowler's position 4) Side-lying with knees drawn up to the chest.

D.

A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? 1) "The bright light in this room is really bothering me." 2) "My eye really itches, but I'm trying not to rub it." 3) "It's really hard to see with a patch on one eye." 4) "I need something for the horrible pain in my eye."

D.

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notify the charge nurse. 4) Test the drainage for glucose.

D.

A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? 1) Hypothermia 2) Hyponatremia 3) Fluid imbalance 4) Airway obstruction

D.

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? 1) "An escharotomy surgically removes dead tissue." 2) "A cannula will be inserted into the bone to infuse fluids and antibiotics." 3) "A piece of skin will be removed and grafted over the burned area." 4) "Large incisions will be made in the burned tissue to improve circulation."

C.

A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? 1) Tell the client to have a family member call the provider to ask what options he plans to recommend. 2) Assure the client that the provider will tell him what is planned. 3) Help the client write down questions to ask his provider. 4) Provide the client with a pamphlet of information about cancer.

C.

A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swallows. 2) Place food on the left side of the client's mouth. 3) Add thickener to fluids. 4) Serve food at room temperature.

D Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs

A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider benefits d. social security as the basis of income

C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently

B Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium.

A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. client with type 2 diabetes taking an oral anti-diabetic agent b. client with heart failure using a salt substitute c. client taking a thiazide diuretic for hypertension d. client taking non-steroidal anti-inflammatory drugs daily

D.

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? 1) Apical pulse rate different than the radial pulse rate 2) Increase in heart rate by 20% when standing 3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position 4) Drop in systolic BP more than 10 mm Hg on inspiration

d. 2 1/5

C

B.

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notify the provider. 2) Verify that the suction regulator is on. 3) Continue to monitor the client because this is an expected finding. 4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.

C.

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? 1) "The pain is worse after I eat a meal high in fat." 2) "My pain is relieved by having a bowel movement." 3) "I feel so much better after eating." 4) "The pain radiates down to my lower back."

C.

A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? 1) Xerostomia 2) Gingivitis 3) Candidiasis 4) Halitosis

A.

A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 1) Bruising 2) Weight loss 3) Hyperpigmentation 4) Double vision

A

A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? 1) Decreased color perception 2) Loss of peripheral vision 3) Bright flashes of light 4) Eyestrain

C.

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? 1) Weight loss of 3% of total body weight. 2) Blood glucose 150 mg/dL. 3) Potassium 2.5 mEq/L 4) Urine specific gravity 1.035

B.

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? A. Cool, clammy skin. B. Hyperventilation C. Increased blood pressure D. Bradycardia

A, B, C, D

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin 5) Symmetrical joint pain

A, B, C, D

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations 5) Bradycardia

A.

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? 1) Loss of peripheral vision 2) Headache 3) Halos around lights 4) Discomfort in the eyes

D.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1) Frothy sputum 2) Dyspnea 3) Orthopnea 4) Peripheral edema

D.

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? 1) A dry raised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin

D.

A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? 1) Serosanguineous drainage 2) Mild erythema 3) Warmth 4) Fever

D.

A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function? 1) Antinuclear antibody 2) C-reactive protein 3) Erythrocyte sedimentation rate 4) Serum creatinine

B.

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea

A.

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? 1) Expiratory wheeze 2) Pleural friction rub 3) Fine rales 4) Rhonchi

A.

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? 1) An expanding circular rash 2) Swollen, painful joints 3) Decreased level of consciousness 4) Necrosis at the site of the bite

D.

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 1) The wound is tender to touch. 2) The wound has pink, shiny tissue with a granular appearance. 3) The wound has serosanguineous drainage. 4) The wound has a halo of erythema on the surrounding skin.

A.

A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? 1) Frequent mood changes 2) Constipation 3) Sensitivity to cold 4) Weight gain

C.

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response

D.

A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? 1) Walk with leg braces and crutches. 2) Drive an electric wheelchair with a hand-control device. 3) Drive an electric wheelchair equipped with a chin-control device. 4) Propel a wheelchair equipped with knobs on the wheels.

d. encourage drinking of cool water or sports drink

C

d. slices of ham and cheese on whole grain crackers

C

C.

A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? 1) Promote the client's expression of feelings about loss of self-care ability. 2) Encourage the client to recall positive life events. 3) Schedule pain medication on a routine basis. 4) Suggest ways the client can continue interacting with social contacts.

C.

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care? 1) Measure abdominal girth daily. 2) Use sterile water to irrigate the nasogastric tube.. 3) Maintain the client in Fowler's position. 4) Moisten the client's lips with lemon-glycerin swabs.

B.

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? 1) Limit fluid intake.. 2) Monitor client's cardinal fields of vision. 3) Encourage ambulation. 4) Ensure the room is brightly lit.

B.

A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? 1) Apply ice to the extremity 2) Monitor platelet levels 3) Restrict oral fluids 4) Administer vasodilating medications

D.

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? 1) Irrigate the nasogastric tube with tap water. 2) Mark abdominal girth once daily. 3) Ambulate the client twice daily. 4) Place the client in a high Fowler's position.

D.

A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personal care activities for her. 2) Limit the client's fluid intake. 3) Monitor the Homan's sign. 4) Maintain abduction of the right hip.

A.

A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? 1) Combing her hair 2) Eating her breakfast 3) Buttoning her blouse 4) Tying her shoes

A.

A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? 1) "I will take a stool softener until my eye is healed." 2) "I will expect to have moderately severe pain for 1-2 days." 3) "I will refrain from cooking for 1 week." 4) "I will bend at the waist to tie my shoes."

D The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, "Perfusion A) is a normal function of the body, and I don't have to be concerned about it." B) varies as a person ages, so I would expect changes in the body." C) is monitored by the physician, and I just follow orders." D) is monitored by vital signs and capillary refill."

C.

A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? 1) Remove the entire dressing at once. 2) Loosen the dressing by pulling the tape away from the wound. 3) Don clean gloves to remove the dressing. 4) Open sterile supplies before removing the dressing.

D.

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmly tell the client that good hygiene is important. 4) Calmly ask the client if he would like to listen to some music.

B.

A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I will refrain from international travel." 4) "I will not order a salad in a restaurant."

C.

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume a low-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day.

A.

A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 2) Place the client's affected leg into the CPM machine with the machine in the flexed position. 3) Place the client into a high Fowler's position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client's bed.

A.

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1) Change the ostomy pouch daily. 2) Empty the ostomy pouch when it is 2/3 full. 3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. 4) Apply lotion to the peristomal skin when changing the ostomy pouch.

A.

A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? A. Avoid bending at the waist. B. Remove the eye shield at bedtime. C. Limit the use of laxatives if constipated. D. Seeing flashes of light is an expected finding following extraction.

D.

A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? 1) "I should increase my intake of protein and vitamin C." 2) "I will no longer have menstrual periods." 3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort." 4) "I will take a tub bath instead of a shower."

B.

A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer? 1) Exposure to environmental pollutants 2) Sun exposure. 3) History of viral illness 4) Scars from a severe burn

A, B, E

A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis 3) Relaxing skeletal muscles 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief

D.

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? 1) "Tonometry is performed to evaluate peripheral vision." 2) "This test will diagnose the type of your glaucoma." 3) "Tonometry will allow inspection of the optic disc for signs of degeneration." 4) "This test will measure the intraocular pressure of the eye."

C.

A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? 1) "A flexible tube is introduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You will remain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed."

C.

A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? 1) On the same day every month 2) Prior to the beginning of menses 3) Three to seven days after menses stops 4) On the second day of menstruation

C.

A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will take this medication until my BUN returns to normal." 2) "This medication will help my new kidney make adequate urine." 3) "I will need to take this medication for the rest of my life." 4) "This medication will boost my immune system."

D.

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will carry a complex carbohydrate snack with me when I exercise." B. "I should exercise first thing in the morning before eating breakfast." C. "I should avoid injecting insulin into my thigh if I am going to go running." D. "I will not exercise if my urine is positive for ketones."

A.

A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? 1) Vitamin B12 2) Vitamin C 3) Iron 4) Folate

A.

A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? 1) "You should wear glasses instead of contacts while taking this medication." 2) "The medication causes amenorrhea if taken along with an oral contraceptive." 3) "A yellow tint to the skin is an expected reaction to the medication." 4) "Lifelong treatment with this medication is necessary."

B.

A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? 1) Omit your daily dose of aspirin. 2) Take a laxative the evening before the procedure. 3) Expect to be drowsy for 24 hr following the procedure. 4) You will feel cold chills after the dye has been injected.

B.

A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? 1) Cottage cheese 2) Fresh berries 3) Bran cereal 4) Skim milk

A.

A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1) "I will keep my house at a cool temperature." 2) "I will try to anticipate and avoid stressful situations." 3) "I will complete the smoking cessation program I started." 4) "I will wear gloves when removing food from the freezer."

A.

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? A. Take temperature once a day. B. Wash the armpits and genitals with a gentle cleanser daily. C. Change the litter boxes while wearing gloves. D. Wash dishes in warm water.

C.

A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? 1) Vitamin D 2) Vitamin A 3) Iron 4) Niacin

C.

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? 1) "When my vision improves, I will be able to stop taking the eye drops." 2) "If I forget to take my eye drops, I should wait until the next time they are due." 3) "I should call the clinic before taking any over-the-counter medications." 4) "Every two years I will need to have my vision checked by an eye doctor."

A.

A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? 1) "I will take the medication with orange juice." 2) "I should expect to have loose stools while taking this medication." 3) "I will have clay colored stools while taking this medication." 4) "I should take the medication with milk."

D.

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? 1) "I will avoid crossing my legs at the knees." 2) "I will use a thermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "I will wear stockings with elastic tops."

B, C, E

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) 1) Polyuria 2) Blurry vision 3) Tachycardia 4) Polydipsia 5) Sweating

A.

A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1) Take the medication 45 minutes before eating. 2) Expect diaphoresis as a side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take the medication. 4) Treat nasal rhinitis with an over-the-counter antihistamine.

D.

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? 1) Empty the pouch immediately after meals. 2) Change the entire appliance once a day. 3) Limit fluid intake. 4) Avoid medications in capsule or enteric form.

C.

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occurs as a residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain is caused from the nitrous dioxide injected into the abdomen."

B.

A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? 1) Temporary, reversible loss of brain function 2) Forgetfulness gradually progressing to disorientation 3) Sleeping more during the day than nighttime 4) Hyper vigilant behaviors

C.

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? 1) Serum sodium 145 mEq/L 2) Urine specific gravity 1.028 3) Urine output 650 mL/hr 4) Blood glucose 198 mg/dL

d. younger adult client receiving hypertonic IV fluid

C

B.

A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make? 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratory alkalosis

B.

A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? 1) Increase in serum glucose 2) Increase in serum creatinine 3) Decrease in white blood cell count 4) Decrease in platelets

C.

A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? 1) Apply topical antifungal agents. 2) Apply fresh ice packs every 4 hr. 3) Wash daily with an antibacterial soap. 4) Keep draining lesions uncovered to air dry.

A.

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? A. Cover the client's wound with a moist, sterile dressing. B. Have the client lie supine with knees flexed. C. Check the client's vital signs. D. Inform the client about the need to return to surgery.

C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement, power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved in motivation.

A patient expresses a strong interest in returning to their work, family, and hobbies after having a stroke. Which theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style? a. field b. biological c. cognitive d. sociologic

C Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.

A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? A) The patient will demonstrate coping skills needed to manage hypertension. B) The patient will verbalize the side effects of treatment. C) The patient will select the type of learning materials they prefer. D) The patient will verbalize an understanding of the importance of following the regimen.

B Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

A patient is being treated with an antibiotic. The nurse explains to the patient that this medication is required for the reduction of inflammation at the injury site because this medication: A) will decrease the pain at the site. B) helps to kill the infection causing the inflammation. C) will reduce the patients fever. D) inhibits cyclooxygenase.

B Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. The nurse should tell the patient that: A) ice is not recommended for use on the sprain because it would inhibit the inflammatory response. B) ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days. C) she should use ice only when the ankle hurts. D) she should wrap an ice pack around the injured ankle for the next 24 to 48 hours.

B A patient with arterial insufficiency is taught to position their legs in a dependent position to use gravity to help perfuse the tissues. Crossing legs at the knee may interfere with blood flow. Slightly bent legs do not enhance blood flow.

A patient states that his/her legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patient's lower leg and the patient has a thready posterior tibial pulse. How would the nurse position the patient's legs? A) Slightly bent with a pillow under the knees B) Dependent position C) Elevated D) Crossed at the knee

The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/2 d. 2 1/5

C 60/40 (desired/have)

C The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client? A) "You may experience an irregular heartbeat while on the drug." B) "Watch for blood in your urine while taking this drug." C) "Use a second form of birth control while on the drug." D) "You will experience increased menstrual bleeding while on this drug."

An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply) a. Serum creatinine and blood urea nitrogen (BUN) b. Sensation in feet and legs c. Skin condition of lower extremities d. Visual acuity e. Signs of respiratory tract infection

A, B, C, D

F) Mental status

A, B, C, F

A client is admitted with infection and a high fever. Which assessments by the nurse take priority? (Select all that apply.) A) Skin turgor B) Pulse quality C) Blood pressure D) Bowel sounds E) Respiratory effort F) Mental status

A, B, C, F Dehydration can accompany fever, especially if the client is sweating profusely. Blood pressure, pulse quality, and skin turgor are assessments of fluid status. Mental status changes can accompany fluid losses, especially in older clients.

D) Uninsured or underinsured status

A, B, D

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) A) High cost of medications B) Inadequate nutrition C) Easy access to health screenings D) Uninsured or underinsured status

A, B, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection.

E) allow closed system containers to hang for 24 hours

A,B,C,E

Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? SELECT ALL THAT APPLY!! A) check the residual volume every 4-6 hours B) use clean technique when changing the feeding system C) keep the head of the beg elevated at least 30 degrees D) change the feeding bag & tubing every 12 hours E) allow closed system containers to hang for 24 hours

A,B,C,E

E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses

A,B,D

The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation. A) Oral temperature 38.6 F B) WBC 20 C) Thick, green nasal discharge D) Patient reports, "I'm tired all the time. I haven't felt like myself in days" E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses

A,B,D Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

F) Pulmonary hypertension

A,B,D,E

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) A) S3/S4 summation gallop B) Cough worsens at night C) Dependent edema D) Pulmonary crackles E) Confusion, restlessness F) Pulmonary hypertension

A,B,D,E Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.

F) Inability to afford a new pair of glasses

A,B,E,F

When reviewing an older client's medical record, which findings lead the nurse to perform a nutrition assessment? (Select all that apply.) A) Widow/widower status B) Chronic constipation C) Cholecystectomy 4 years ago D) Random blood sugar level of 198 mg/dL E) History of depression F) Inability to afford a new pair of glasses

A,B,E,F Many factors contribute to malnutrition in older clients. Depression and loneliness from the loss of a spouse; constipation; poor eyesight; chronic medical problems, including depression; and taking prescription and/or over-the-counter medications can contribute to malnutrition. Blood glucose levels and a previous cholecystectomy would not necessarily contribute.

F) Oxygen saturation level is 98%.

A,B,F

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) A) There is presence of quiet, effortless breath sounds at lung base bilaterally. B) Nail beds are pink with good capillary refill. C) Trachea is just to the left of the sternal notch. D) Respiratory rate is 24 breaths/min. E) The right side of the thorax expands slightly more than the left. F) Oxygen saturation level is 98%.

A,B,F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

After initial placement of NG tubes is confirmed, how often must placement be checked? SELECT ALL THAT APPLY? A) before medication administration B) it is not necessary to recheck placement C) every 4-8 hours during feeding D) before intermittent feeding E) according to facility policy

A,C,E

E) according to facility policy

A,C,E

F) Restlessness

A,C,E,F

Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pressure C) Crying D) Decreased respirations E) Facial grimace F) Restlessness

A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations.

F) Warmth

A,D,E,F

The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.) A) Redness B) Fever C) Increased erythrocyte sedimentation rate (ESR) D) Pain E) Swelling F) Warmth

A,D,E,F Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection.

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds

A. A carotid bruit

156. A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? A) Double vision and visual halos B) Extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight

B

D) Having the client cough and deep breathe hourly

B

D) Hypnosis

B

D) It converts excess glucose into glycogen, lowering blood glucose levels in times of excess.

B

D) Join a support group for people with COPD.

B

D) Maintaining an oral intake of at least 1500 mL/day

B

D) Plasma cells and B-lymphocytes

B

D) Position the client with the unaffected side down.

B

D) Postoperative client with a neck incision

B

D) Prepare to administer a bronchodilator.

B

A,C,E

After initial placement of NG tubes is confirmed, how often must placement be checked? SELECT ALL THAT APPLY? A) before medication administration B) it is not necessary to recheck placement C) every 4-8 hours during feeding D) before intermittent feeding E) according to facility policy

B The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, background, or assessment.

An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand-off? A) Situation B) Recommendation C) Background D) Assessment

D) The client's thyroxine (T4) level is 8 mcg/dL.

B

D Because of an age-related decline in immune function, an older adult's normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.

An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate? A) Document the findings and continue to monitor. B) Assess the client's pain level and treat if needed. C) Perform a Mini-Mental Status Examination. D) Assess the client for other signs of infection.

D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints.

An older adult client is in physical restraints. Which intervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.

A Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to dig toxicity.

An older adult client presents with signs and symptoms related to dig toxicity. Which age related change may have contributed to this problem? a. decreased renal blood flow b. increased gastrointestinal motility c. decreased ratio of adipose tissue to lean body mass d. increased total body water

B,C,D,E Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted.

An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.) A) Morphine (Durmorph) B) Meperidine (Demerol) C) Propoxyphene (Darvocet) D) Methadone (Dolophine) E) Codeine

Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.

Ana's postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question? A. Put the client in modified Trendelenberg's position. B. Administer oxygen at 100%. C. Monitor urine output every hour. D. Administer Demerol 50mg IM q4h

D. "I will give you the pain medication the physician ordered."

Answer: (C) "With a pillow, apply pressure against the incision."

Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse's best response would be: A. "Pain will become less each day." B. "This is a normal reaction after surgery." C. "With a pillow, apply pressure against the incision." D. "I will give you the pain medication the physician ordered."

Answer: (C) "With a pillow, apply pressure against the incision." Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.

D. The patient is anxious about upcoming surgery

Answer: (C) This is normal side-effect of AtSO4

Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse's best A. The patient is having an allergic reaction to the drug. B. The patient needs a higher dose of this drug C. This is normal side-effect of AtSO4 D. The patient is anxious about upcoming surgery

Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.

D. have altered mental function

Answer: (C) experience reduced sensory perception

The nurse needs to carefully assess the complaint of pain of the elderly because older people A. are expected to experience chronic pain B. have a decreased pain threshold C. experience reduced sensory perception D. have altered mental function

Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.

D. "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?"

Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?"

Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach? A. "Good evening, Mr. Pablo. Wasn't it a pleasant day, today?" B. "Mr, Pablo, you must be so worried, I'll leave you alone with your thoughts. C. "Mr. Pablo, you'll wear out the hospital floors and yourself at this rate." D. "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?"

Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?" The client is showing signs of anxiety reaction to a stressful event. Recognizing the client's anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.

D. Administer Demerol 50mg IM q4h

Answer: (D) Administer Demerol 50mg IM q4h

Ana's postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question? A. Put the client in modified Trendelenberg's position. B. Administer oxygen at 100%. C. Monitor urine output every hour. D. Administer Demerol 50mg IM q4h

Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.

D) To determine whether pain is influencing blood pressure and heart rate

B

D) decreased respirations.

B

D) inhibits cyclooxygenase.

B

D) provide a warm blanket.

B

100. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw

B

103. The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? A) "Activated charcoal decreases the systemic absorption of the poison from the stomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body by the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by children or adults."

B

104. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) "Please state your name?" Upon entering the room the nurse should ask: B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) "Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"

B

D) she should wrap an ice pack around the injured ankle for the next 24 to 48 hours.

B

105. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis

B

117. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

B

120. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) "I must document and report any information." B) "I can't make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team."

B

123. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) A pacemaker inserted this morning with intermittent capture

B

128. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A) A 76-year-old client with severe depression B) A middle-aged client with an obsessive compulsive disorder C) A adolescent with dehydration and anorexia D) A young adult who is a heroin addict in withdrawal with hallucinations

B

129. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A) Encourage oral fluids for the temperature elevation B) Check temperature 15 minutes after hot liquids are taken C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet

B

13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles

B

130. A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. The best response by the charge nurse would be to A) Keep the client's room door cracked to minimize the distractions B) Assign 1 of the nursing staff to visit the client regularly C) Reassure the client that 1 staff person will check frequently if the client needs anything D) Arrange for each staff member to go into the client's room to check on needs every hour on the hour

B

131. A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) The results of a standardized tool that measures depression B) Observation of affect and behavior C) Inquiry about use of alcohol D) Family history of emotional problems or mental illness

B

135. An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A) An adolescent who was admitted the day before with acute situational depression B) A middle aged person who has been on the unit for 72 hours with a dysthymia C) An elderly person who was admitted 3 hours ago with cycothymia D) A young adult who was admitted 24 hours ago for detoxification

B

140. An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options

B

145. A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) Photograph the specific injuries in question

B

15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses

B

151. Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? A) "It is to observe reactive service and product problem solving." B) Improvement of the processes in a proactive, preventive mode is paramount. C) A chart audits to finds common errors in practice and outcomes associated with goals. D) A flow chart to organize daily tasks is critical to the initial stages.

B

155. The nurse is teaching about non steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A) Reporting joint stiffness in the morning B) Taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving D) Continuing to take aspirin for short term relief

B

157. The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." B) "He has had an ear infection for the past 2 days." C) "He has been eating more red meat lately." D) "He seems to be going to the bathroom more frequently."

B

158. A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) Monitor respiratory status D) Assess for mental status changes

B

159. An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine

B

17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

B

22. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake

B

23. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication

B

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

B

3. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A)It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B)It is critical to report promptly to your health care provider any findings of peptic ulcers c)Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D)With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

B

30. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."

B

31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."

B

36. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

B

37. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises

B

4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output

B

43. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation

B

47. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator

B

48. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap."

B

55. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion

B

The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient? A) 8 mL B) 7.5 mL C) 7 mL D) 5.5 mL

B

d. client taking non-steroidal anti-inflammatory drugs daily

B

59. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication."

B

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

B

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

B

64. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin

B

66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended

B

67. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets

B

72. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

B

75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight

B

79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A)Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream

B

81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

B

84. Which statement best describes the effects of immobility in children? A) Immobility prevents the progression of language and fine motor development B) Immobility in children has similar physical effects to those found in adults C) Children are more susceptible to the effects of immobility than are adults D) Children are likely to have prolonged immobility with subsequent complications

B

87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

B

88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements

B

D) "Daily weights will help us make sure that you're eating properly."

B

D) "Massage the injection site after the heparin is injected."

B

D) "These coverings protect you from getting an infection from me."

B

D) "Watch your diet while on this medication."

B

D) "Your doctor knows best and has ordered this treatment for you."

B

D) 5.5 mL

B

D) Administer an aspirin on a daily basis.

B

D) Administration of warmed IV fluids

B

D) Ankle discoloration and pitting edema

B

D) Assessment

B

D) Burning on urination

B

D) Check for a blood return.

B

D) Check the IV for patency.

B

D) Client taking a sulfonamide antibiotic

B

D) Client who has pneumonia

B

D) Client who has undergone an appendectomy

B

D) Cluster nursing procedures together to avoid fatiguing the client.

B

D) Crampy lower abdominal pain

B

D) Crossed at the knee

B

D) Document the finding per protocol.

B

D) Ensuring that the client is eating 100% of the meals served to him or her

B

D) Furosemide (Lasix) 20 mg PO now

B

A patient states that his/her legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patient's lower leg and the patient has a thready posterior tibial pulse. How would the nurse position the patient's legs? A) Slightly bent with a pillow under the knees B) Dependent position C) Elevated D) Crossed at the knee

B A patient with arterial insufficiency is taught to position their legs in a dependent position to use gravity to help perfuse the tissues. Crossing legs at the knee may interfere with blood flow. Slightly bent legs do not enhance blood flow.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? A) KCl 20 mEq PO two times per day B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr C) Oxygen via face mask at 8 L/min D) Furosemide (Lasix) 20 mg PO now

B A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention related to this assessment? A) Increase the client's fluid intake. B) Consult with the health care provider. C) Reassess the client in 3 days. D) Document the finding per protocol.

B A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protection measures than are currently provided.

The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important? A) Double check the "five rights." B) Assess the client for allergies. C) Teach the client about the drug. D) Check the IV for patency.

B All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction.

A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide? A) "Take the drug with food or milk." B) "Report any abdominal pain or dark-colored vomit." C) "Expect to experience weight gain." D) "Watch your diet while on this medication."

B All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration.

Which action does the nurse teach a client to reduce the risk for dehydration? A) Avoiding the use of glycerin suppositories to manage constipation B) Maintaining a daily oral intake approximately equal to daily fluid loss C) Restricting sodium intake to no greater than 4 g/day D) Maintaining an oral intake of at least 1500 mL/day

B Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.

A patient is being treated with an antibiotic. The nurse explains to the patient that this medication is required for the reduction of inflammation at the injury site because this medication: A) will decrease the pain at the site. B) helps to kill the infection causing the inflammation. C) will reduce the patients fever. D) inhibits cyclooxygenase.

B Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever.

The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client? A) "You must have your aPTT checked every 2 weeks." B) "Notify your health care provider if your stools appear tarry." C) "An IV catheter will be placed to administer your heparin." D) "Massage the injection site after the heparin is injected."

B As with any anticoagulation, low-molecular-weight heparin incurs risk of bleeding. Clients should be taught to report to their health care provider the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae. Low-molecular-weight heparin does not affect activated partial thromboplastin time (aPTT), as does intravenous heparin. This type of heparin is administered subcutaneously to deliver a slow sustained response. Massaging the site would hasten absorption and decrease effects.

The nurse is caring for four clients. Which client assessment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision

B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.

The nurse assesses a cut that is 24 hours old and finds that the site is swollen, red, and tender to the touch. Which cell types are responsible for these assessment findings? A) Natural killer cells B) Basophils and eosinophils C) Erythrocytes and platelets D) Plasma cells and B-lymphocytes

B Basophils and eosinophils release histamine, kinins, and other substances that cause the manifestations of inflammation. Erythrocytes carry oxygen, and platelets help stop bleeding. Plasma cells and B-lymphocytes produce antibodies to help fight infection, and natural killer cells destroy invading bacteria.

Which client does the nurse assess to be at greatest risk for pressure ulcer development? A) Client who requires assistance with ambulation B) Incontinent client with limited mobility C) Client with hypertension on multiple medications D) Client who has pneumonia

B Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. Clients with pneumonia and hypertension do not have specific risk factors. The client who needs assistance with ambulation might be at moderate risk if he or she does not move about much, but having two risk factors makes the last option the person at highest risk.

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site? A) Apply a cold compress. B) Discontinue the infusion. C) Slow the rate of infusion. D) Check for a blood return.

B Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she should immediately stop the infusion. Even if the IV has a good blood return, some of the chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the correct action, depending on the specific agent. However, the compress would be applied only after the infusion has been discontinued.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiving intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a sulfonamide antibiotic

B D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? A) "The hospital requires that all inpatients be weighed daily." B) "Weight is the best indication that you are gaining or losing fluid." C) "You need to lose weight to decrease the incidence of heart failure." D) "Daily weights will help us make sure that you're eating properly."

B Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency? A) Pain with activity but not while resting B) Dependent mottling and absence of hair C) Full veins present in dependent extremity D) Ankle discoloration and pitting edema

B Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain may be present with activity and at rest. Edema and ankle discoloration would be indicative of venous insufficiency.

The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks. The client states that she is hungry all the time and doesn't understand why. Which assessment finding could explain the client's weight gain and hunger? A) The client's glycosylated hemoglobin level is 6%. B) The client started taking dexamethasone (Decadron) daily. C) The client started taking naproxen sodium (Naprosyn) daily. D) The client's thyroxine (T4) level is 8 mcg/dL.

B Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism, predisposing the client to obesity when taken on a long-term basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric upset and ulceration and decreased appetite and weight loss. The client's glycosylated hemoglobin and thyroid levels are within normal limits and would not explain the hunger and weight gain.

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? A) Position with the head of the bed flat to enhance cerebral perfusion. B) Monitor neurologic and vital signs closely to identify early changes in status. C) Administer prescribed analgesics to promote pain relief. D) Cluster nursing procedures together to avoid fatiguing the client.

B Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours.

The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? A) It enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. B) It prevents hypoglycemia by promoting release of glucose from liver storage sites. C) It is a storage form of glucose and can be broken down for energy when blood glucose levels are low. D) It converts excess glucose into glycogen, lowering blood glucose levels in times of excess.

B Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis). The other statements are not accurate descriptions of the actions of glucagon.

A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the nurse about using ice on her injured ankle. The nurse should tell the patient that: A) ice is not recommended for use on the sprain because it would inhibit the inflammatory response. B) ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2 days. C) she should use ice only when the ankle hurts. D) she should wrap an ice pack around the injured ankle for the next 24 to 48 hours.

B Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to prevent damage to surrounding tissues from excessive inflammation. Ice should be used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used according to a schedule for it to be effective and not be overused. Using ice more often or for longer periods of time can cause additional tissue damage. Ice is recommended to inhibit the inflammatory process from damaging surrounding tissue.

Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis

B Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli.

The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective? A) Administering an antiemetic medication B) Increasing fluids to 2 L/day if tolerated C) Administering an antitussive medication D) Having the client cough and deep breathe hourly

B Increasing fluids has been proven to decrease the thickness of secretions, thus allowing them to be expectorated quickly. The other interventions would not be as effective.

The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective? A) Performing range-of-motion exercises on the client three times each day B) Assessing the client's respirations when administering opioids C) Delegating to the nursing assistant to give the client a complete bath daily D) Ensuring that the client is eating 100% of the meals served to him or her

B It is important for the nurse to assess respirations of the client when administering opioids because of the possibility of respiratory depression. The other interventions may or may not be necessary in the care of the client and do not focus on safety.

A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI? A) Hematuria B) Fever and chills C) Cloudy, dark urine D) Burning on urination

B Lower urinary tract infections are rarely associated with systemic symptoms of fever and chills. A client with a UTI who develops fever and chills should be assessed for the development of pyelonephritis. The other options can be seen with UTI.

Why does the nurse always ask the client his or her pain level after taking routine vital signs? A) To follow McCaffery's guidelines on pain management B) To ensure that pain assessment occurs on a regular basis C) To determine the need for more frequent vital sign measurement D) To determine whether pain is influencing blood pressure and heart rate

B Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.

A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does the nurse encourage the client to do? A) Participate in community activities. B) Verbalize his or her thoughts and feelings. C) Ask the client's physician for an antianxiety agent. D) Join a support group for people with COPD.

B Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. client with type 2 diabetes taking an oral anti-diabetic agent b. client with heart failure using a salt substitute c. client taking a thiazide diuretic for hypertension d. client taking non-steroidal anti-inflammatory drugs daily

B Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium.

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the nurse prepare for this client FIRST? A) Continuous arteriovenous rewarming B) Dry clothing and warm blankets C) Peritoneal lavage with warmed normal saline D) Administration of warmed IV fluids

B Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia.

A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? A) "I am preventing the spread of infection from you to me or any other client here." B) "The clothing protects me from accidentally absorbing these drugs." C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." D) "These coverings protect you from getting an infection from me."

B Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs.

The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy

B Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.

The nurse is caring for a client with peripheral arterial disease. What priority nursing intervention does the nurse perform to promote vasodilation? A) Increase the client's exercise regimen daily. B) Educate the client to abstain from smoking. C) Apply a heating pad to the affected limb. D) Administer an aspirin on a daily basis.

B Smoking causes vasoconstriction, and its effects can last up to 1 hour after the cigarette is finished. Increasing activity may lead to collateral circulation but does not cause vasodilation. Use of a heating pad is contraindicated in the client with peripheral artery disease because of the risk of a burn caused by diminished sensation. The use of aspirin my impede platelet clumping and is contraindicated only when the client is on anticoagulants.

An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand-off? A) Situation B) Recommendation C) Background D) Assessment

B The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, background, or assessment.

The priority nursing intervention for a patient suspected to be hypothermic would be to: A) hydrate with intravenous (IV) fluids. B) remove wet clothes. C) assess vital signs. D) provide a warm blanket.

B The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? A) "Rehabilitation will reverse any physical deficits caused by the stroke." B) "Rehabilitation will help you function at the highest level possible." C) "If you do not have rehabilitation, you may never walk again." D) "Your doctor knows best and has ordered this treatment for you."

B The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately.

The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? A) Traces of blood in the stool B) Distended abdomen C) Temperature of 100.0° F (37.8° C) D) Crampy lower abdominal pain

B The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease.

The nurse auscultates the following lung sound in the client with pneumonia. What is the best intervention? Audio Clip A) Administer IV fluids. B) Have the client use an incentive spirometer. C) Have the client cough and deep breathe. D) Prepare to administer a bronchodilator.

B The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed by using an incentive spirometer. If no spirometer is available, coughing and deep breathing is the next best option. This client does not have wheezing, so bronchodilators are not indicated. IV fluids would not help atelectasis.

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? A) Teach the client to touch and use both sides of the body. B) Apply sequential compression stockings. C) Instruct the client to turn the head from side to side. D) Position the client with the unaffected side down.

B To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility.

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates: A) slow capillary refill. B) red, sweaty skin. C) low pulse rate. D) decreased respirations.

B With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

39. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

B . 40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs C

96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

B 97. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact D

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply) a. Monitor dryness of mucous membranes b. Check for changes in mentation c. Observe color of skin and nailbeds d. Note appearance of jugular veins e. Assess breathing patterns

B, C, E

F) Pulmonary system

B, E, F

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) A) Endocrine system B) Neurologic system C) Hepatic system D) Immune system E) Cardiovascular system F) Pulmonary system

B, E, F The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

G) Limit fluids and proteins in the diet.

B,C,D

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.) A) Use a rubber ring to decrease sacral pressure when up in the chair. B) Place a small pillow between bony surfaces. C) Keep the heels off the bed surfaces. D) Use a lift sheet to assist with repositioning. E) Reposition the client who is in a chair every 2 hours. F) Elevate the head of the bed to 45 degrees. G) Limit fluids and proteins in the diet.

B,C,D A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

E) Codeine

B,C,D,E

An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.) A) Morphine (Durmorph) B) Meperidine (Demerol) C) Propoxyphene (Darvocet) D) Methadone (Dolophine) E) Codeine

B,C,D,E Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted.

G) Diuretics

B,C,D,F,G

The nurse prepares to teach a patient recovering from a myocardial infarction (MI) about combination durg therapy based on "best practice" for controlling hypertension. Which drugs does the nurse include in the teaching plan? SELECT ALL THAT APPLY!!! A) NSAID's B) Aspirin C) Aldosterone antagonists D) ACE Inhibitors or ARB's E) Central alpha Agonists F) Beta Blockers G) Diuretics

B,C,D,F,G

E) Administer vitamin K

B,D

The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.) A) Laboratory draw for prothrombin time (PT)/international normalized ratio (INR) B) Laboratory draw for activated partial thromboplastin time (aPTT) C) Administer enoxaparin (Lovenox) D) Administer protamine sulfate E) Administer vitamin K

B,D Protamine sulfate is the antidote for heparin-induced bleeding. Vitamin K is the antidote for warfarin. Warfarin (Coumadin) would increase bleeding. Enoxaparin is another name for heparin.

34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak

C

A.

Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause? 1) "Do you sleep well at night?" 2) "Have you been experiencing chills?" 3) "Have you experienced increased hair growth?" 4) "When did you begin your menses?"

D) "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity."

C

B Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli.

Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis

101. After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness

C

11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter

C

111. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room

C

114. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus

C

115. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."

C

119. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic

C

12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive

C

122. A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first A) Focus on reality orientation to place and person B) Assist with the report of the client's complaint to the police C) Obtain more details of the client's claim of abuse D) Document the statement on the client's chart with a report to the manager

C

137. A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states "everyone's life is in God's hands." The next action for the nurse to take is to A) Report the situation to the health care provider B) Discuss the situation with the client's family C) Ask the client if talking with a priest would be desired D) Document the situation on the notes

C

138. A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client's drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) "These pills aren't antacids since they are all different." B) "Some teenagers use pills to lose weight." C) "Tell me about your week prior to being admitted." D) "Are you taking pills to change your weight?"

C

141. Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) "I think all children should have their heads shaved." B) "I have been restricted in thought and harmed." C) "I have powers to get you whatever you wish, no matter the cost." D) "I think all of my contacts last week have attempted to poison me."

C

150. A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of A) Prejudice B) Discrimination C) Stereotyping D) Racism

C

153. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? A) Tachycardia blurred vision, hypotension, anorexia B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) Photosensitivity, seizures, edema, hyperglycemia

C

33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms

C

42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

C

45. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output

C

46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

C

5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea

C

53. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure

C

54. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."

C

57. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time

C

73. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence

C

77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs

C

8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A)Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

C

82. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerine suppositories B) Fiber supplements C) Laxatives D) Stool softeners

C

85. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently

C

89. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain

C

9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A)It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B)In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C)Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D)Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks

C

91. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors

C

92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

C

98. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.

C

The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse? A) Having the urge to void continuously while the catheter is inserted B) Passing small blood clots after catheter removal C) Having bright red drainage with multiple blood clots D) Experiencing urinary frequency after catheter removal

C A client who undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the catheter is removed. However, the presence of bright red blood with clots indicates arterial bleeding and should be reported to the provider.

A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse implements? A) Place the client in bed and instruct him or her to elevate the foot. B) Prepare for and assist with obtaining a wound culture. C) Assess the affected leg for pulses, skin color, and temperature. D) Draw blood for albumin, prealbumin, and total protein.

C A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after it has been determined drainage, odor, and other risks for infection are present. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done.

Which finding puts a client at greatest risk for wound infection? A) Presence of a deep wound B) Coexisting medical conditions C) Immune compromised status D) Severely reddened skin

C A compromised immune system puts a client at greatest risk for infection. Although all the other options might increase the client's susceptibility, the one with the greatest potential impact is being immune compromised.

A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action? A) Document as a stage I pressure ulcer and apply a transparent dressing. B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments. C) Document as a stage IV pressure ulcer and prepare the client for débridement. D) Document as a stage III pressure ulcer and start antibiotic therapy.

C A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the necrotic tissue and a possible graft to promote healing.

A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? A) The patient will demonstrate coping skills needed to manage hypertension. B) The patient will verbalize the side effects of treatment. C) The patient will select the type of learning materials they prefer. D) The patient will verbalize an understanding of the importance of following the regimen.

C Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.

Which person is at greatest risk for developing a community-acquired pneumonia? A) Young adult aerobics instructor who is a vegetarian B) Middle-aged teacher who typically eats a diet of Asian foods C) Older adult who smokes and has a substance abuse problem D) Older adult with exercise-induced wheezing

C Although age is a factor in the development of community-acquired pneumonia, other lifestyle and exposure factors increase the risk to a greater extent than age. Two conditions that heavily predispose to the development of pneumonia are cigarette smoking and alcoholism. Dietary choices typically do not predispose to the development of pneumonia. Cigarette smoking interferes with the ciliary function of removal of invasive materials. Alcoholism usually results in unbalanced nutrition, as well as decreased immune function. A middle-aged adult, an older adult with wheezing induced by exercise, and a young adult vegetarian would not be at risk for community-acquired pneumonia because they have no predisposing conditions.

The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action? A) Turn off the heparin before administering the warfarin. B) Clarify the warfarin order with the nursing supervisor. C) Administer both heparin and warfarin as prescribed. D) Hold the warfarin dose until the heparin is discontinued.

C Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client's heparin can be safely discontinued. Effects of heparin will be cleared from the client's bloodstream within a few hours.

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? A) Skin integrity B) Blood pressure C) Heart rate and rhythm D) Abdominal percussion

C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

The client with type 2 diabetes has recently been changed from the oral antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to glyburide-metformin (Glucovance). The nurse includes which information in the teaching about this medication? A) "Glucovance is more effective than glyburide and metformin." B) "Your diabetes is improving and you now need only one drug." C) "Glucovance contains a combination of glyburide and metformin." D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents."

C Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.

The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication.

C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out.

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently

C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, including steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain crackers

C Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium.

A client has a urinary tract infection. Which assessment by the nurse is most helpful? A) Palpating and percussing the kidneys and bladder B) Performing a bladder scan to assess post-void residual C) Assessing medical history and current medical problems D) Inquiring about recent travel to foreign countries

C Clients who are severely immune compromised or who have diabetes mellitus are more prone to fungal urinary tract infection. The nurse should assess for these factors. A physical examination and a post-void residual may be needed, but not until further information is obtained. Travel to foreign countries probably would not be as important, because even if exposed, the client needs some degree of immune compromise to develop a fungal urinary tract infection.

During assessment of a client with a 15-year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first? A) Notify the health care provider. B) Document the finding in the client's chart. C) Examine the client's feet for signs of injury. D) Test sensory perception in the client's hands.

C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessing, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? A) Turn on the television to a 24-hour news station. B) Provide auditory and visual stimulation simultaneously. C) Ask the family to bring in pictures familiar to the client. D) Maintain a calm and quite environment by minimizing visitors.

C For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? A) Healthy individual, college educated, travels frequently, can balance a checkbook B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volunteers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed

C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? A) Examine sacral area and patient's heels for skin breakdown due to potential edema. B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures. C) Institute fall precautions due to potential postural hypotension and weak leg muscles. D) Raise bed side rails due to potential decreased level of consciousness and confusion.

C Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

Which client is at highest risk of compromised immunity? A) Client with extreme anxiety B) Client who is awaiting surgery C) Client who has just had surgery D) Client who just delivered a baby

C Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a portal for organisms to enter the body and cause infection.

The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first action? A) Administering oxygen by nasal cannula B) Documenting the findings and continuing to monitor C) Arousing the client by calling his or her name D) Administering naloxone (Narcan) IV push

C Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no further intervention is required.

A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? A) Interferon beta-1b (Betaseron) B) Baclofen (Lioresal) C) Methylprednisolone (Medrol) D) Dantrolene sodium (Dantrium)

C Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.

Which statement indicates that the client needs more teaching about mucositis? A) "I will use a soft-bristled toothbrush to prevent trauma." B) "I will rinse my mouth with water after every meal." C) "I should use an alcohol-based mouth rinse to kill bacteria." D) "I cannot use floss because it may irritate my gums."

C Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis.

Which client is at greatest risk for dehydration? a. younger adult client on bedrest b. older adult client receiving hypotonic IV fluid c. older adult client with cognitive impairment d. younger adult client receiving hypertonic IV fluid

C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration

The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management? A) No complaints of sexual dysfunction occur. B) Pedal edema is not present in the lower legs. C) No indication of renal impairment is present. D) The blood pressure reading is 148/94 mm Hg.

C One expected outcome for a client with hypertension is for the client to have no evidence of target organ damage, such as renal or heart disease, that can occur with poorly managed hypertension. Development of pedal edema is not directly related to the management of hypertension. Side effects of some hypertensive agents may interfere with sexual function, but this does not relate to the effectiveness of treatment for hypertension. The blood pressure reading is too high to demonstrate effective management.

What is my favorite football team? A) I hate football!! B) the Fightin' Irish C) GO BUCKS!!!! D) that team up north

C Seriously, if you don't know the instructor's favorite football by this time, you need to listen to your recordings from the first lecture. Just sayin'

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? A) "I sleep with four pillows at night." B) "I wake up coughing every night." C) "My shoes fit really tight lately." D) "I have trouble catching my breath."

C Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

O-H- A) who cares! B) I cannot pick this so I will lose points (this is for the Michigan Fans!!) C) I-O D) O-No!!

C Sucking up here with C may be dependent on how low your accumulative test scores are...

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? A) Documenting all changes observed in the client and maintaining a postoperative flow sheet B) Monitoring the client for changes in postoperative status such as wound infection C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic D) Notifying the physician of the client's increase in restlessness after medication change

C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client's status after a medication change would not be considered activities of the Rapid Response Team.

A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? A) Restrict fluid intake. B) Prevent ketosis. C) Control hyperglycemia. D) Prevent hypoglycemia.

C Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? A) "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." B) "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis." C) "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." D) "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity."

C The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.

A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes priority? A) Auscultate bowel sounds and slow the feeding down. B) Remove the tube immediately and notify the heath care provider. C) Auscultate lung sounds and obtain oxygen saturation. D) Add blue dye to the feeding tube formula.

C The client may have aspirated. The nurse should further assess the client's respiratory and oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful.

A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client? A) "You may experience an irregular heartbeat while on the drug." B) "Watch for blood in your urine while taking this drug." C) "Use a second form of birth control while on the drug." D) "You will experience increased menstrual bleeding while on this drug."

C The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? A) Position the client to allow gravity drainage of the fistula. B) Check and record blood glucose levels every 6 hours. C) Encourage the client to consume a diet high in protein and calories. D) Monitor the client's hematocrit and hemoglobin.

C The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse correlate with this condition? A) Expiratory wheeze on the right side B) Crackles heard on expiration bilaterally C) Dullness to percussion on the lower left side D) Crepitus of the skin around the left lung

C The client with pneumonia may have dullness to percussion on the affected side. The other options are all inconsistent with pneumonia.

The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals. D) Complete the nursing care plan.

C The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client.

The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehydrated client. C) Use sterile technique when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%.

C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to: A) bathe and dry the skin vigorously to stimulate circulation. B) limit intake of fluid and offer frequent snacks. C) turn the patient at least every 2 hours. D) keep the head of the bed elevated 30 degrees.

C The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

The nurse is caring for an anorexic client who is severely malnourished. A nasogastric feeding tube is inserted, and tube feedings are started. Which laboratory finding is the best indication that the client's nutritional status is improving? A) Creatinine has dropped from 1.9 to 0.5 mg/dL. B) Blood urea nitrogen (BUN) level has dropped from 15 to 11 mg/dL. C) Prealbumin level has risen from 9 to 13 mg/dL. D) Sodium has risen from 130 to 144 mg/dL.

C The prealbumin level is a good measure of nutritional status because its half-life is only 2 days, so it reflects current nutritional status. The client's prealbumin level is rising and almost normal, indicating that the client's nutritional status is improving. The other laboratory values are more reflective of fluid balance and kidney function.

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse? a. admin tylenol 650 mg orally b. encourage rest, and reassess in 15 minutes c. sponge the victim with cool water and remove his shirt d. encourage drinking of cool water or sports drink

C The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment

The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time? A) 30 seconds B) 150 seconds C) 60 seconds D) 15 seconds

C Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.

The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client? A) Absence of hair on the left lower extremity B) Skin surrounding the ulcer mottled but blanchable C) Brownish discoloration of the lower extremity D) Cold and gray-blue lower extremity

C Venous ulcers are characterized by brown pigmentation of the skin of the lower extremity. Mottled skin, the presence of dependent rubor, and cyanosis are features of arterial ulcers.

f. a young woman who is diabetic

C, D, E, F

The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (select all that apply) a. an older woman with hypertension b. a young man with a body mass index of 42 c. a young many who has just consumed six martinis d. an older man who smokes a pack of cigarettes a day e. a young woman who is anorexic f. a young woman who is diabetic

C, D, E, F clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.

To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), what interventions should the nurse implement? a. initiate passive range of motion b. establish a regular routine c. teach the client breathing exercises d. perform chest physiotherapy e. encourage use of incentive spirometer

C, E

G) "Rest before meals if you have dyspnea."

C, E, G

What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) A) "Eat dry foods rather than wet foods, which are heavier." B) "Increase carbohydrate intake for energy." C) "Have about six small meals a day." D) "Practice diaphragmatic breathing against resistance four times daily." E) "Avoid drinking fluids just before and during meals." F) "Eat high-fiber foods to promote gastric emptying." G) "Rest before meals if you have dyspnea."

C, E, G Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition.

F) Discomfort or pain with elimination

C,D,E,F

When conducting a health history assessment, the nurse would want to know what important information about the patient's elimination status? (Select all that apply.) A) Time of day patient defecates B) Patient's preferences for toileting C) List of medications taken by patient D) Recent changes in elimination patterns E) Changes in color, consistency, or odor of stool or urine F) Discomfort or pain with elimination

C,D,E,F Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patient's preferences for toileting. They are personal preferences and do not affect elimination.

F) Profuse perspiration

C,D,F

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) A) Constricted pupils B) Flushed skin C) Tremors D) Nervousness E) Extreme thirst F) Profuse perspiration

C,D,F When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

A patient expresses a strong interest in returning to their work, family, and hobbies after having a stroke. Which theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style? a. field b. biological c. cognitive d. sociologic

C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement, power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved in motivation.

d. sociologic

C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement, power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved in motivation.

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. follows formalized plans b. has standardized content c. often occurs one-to-one d. addresses group needs

C. Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. follows formalized plans b. has standardized content c. often occurs one-to-one d. addresses group needs

C. Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

d. addresses group needs

C. Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

116. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client's written consent before I release any information to you.

D

121. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch

D

A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction

1. Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

D

1. Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

D

102. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen

D

108. A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to A) Move any chairs or desks at least 3 feet away from the child B) Note the sequence of movements with the time lapse of the event C) Provide privacy as much as possible to minimize fighting the other children D) Place the hands or a folded blanket under the head of the child

D

110. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields

D

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

D

124. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?"

D

125. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client

D

126. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigate D) Perform nostril and mouth care

D

132. A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? A) The refusal of any treatment for self and the neonate until she talks to a reader B) The placement of a rosary necklace around the neonate's neck and not to remove it unless absolutely necessary C) Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."

D

133. An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's response is an example of A) Discrimination B) Stereotyping C) Ethnocentrism D) Prejudice

D

134. A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is A) "I apologize for the delay. I was involved in an emergency." B) "Let's talk. Why are you upset about this?" C) "I am surprised that you are upset. The request could have waited a few more minutes." D) "I see this is frustrating for you. I have a few minutes so let's talk."

D

142. A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas

D

143. During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) "I wonder who is paying for this trip to the hospital?" B) "I think she needs to go to the city hospital." C) "All those people indulge in large families!" D) "Doesn't she know there's such a thing as birth control?"

D

146. Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client A) Has revitalized a relationship with her family to help cope with the death of a daughter B) Had recognized regressive behavior as a defense mechanism C) Expresses a desire to be cared for and pampered D) Recognizes feelings with appropriate expression of feelings

D

147. A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? A) Allow the client to randomly move about the holding area until a hospital room is available B) Engage the client in an activity that requires focus and individual effort C) Isolate the client in a secure room until control is regained by the client D) Locate a room that has minimal stimulation outside of it for admission process

D

148. A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? A) Depression B) Anger C) Frustration D) Disbelief

D

149. Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? A) "I am determined to leave my house in a week." B) "No one else in the family has been treated like this." C) "I have only been married for 2 months." D) "I have tried leaving, but have always gone back."

D

152. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy

D

154. The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit

D

16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A)"I knew this would happen. I've been eating too much red meat lately." B)"I really enjoyed my fishing trip yesterday. I caught 2 fish." C)"I have really been working hard practicing with the debate team at school." D)"I went to the health care provider last week for a cold and I have gotten worse."

D

18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

D

19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

D

2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight

D

2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight

D

20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

D

21. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

D

24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

D

25. A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.

D

32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L

D

35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

D

38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene

D

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

D

52. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation

D

56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days

D

58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube

D

60. Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding

D

62. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

D

69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."

D

70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

D

71. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato

D

80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall

D

86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

D

93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

D

95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces

D

D) "Avoid using salt substitutes."

D

D) "Do not take this medication within 1 hour of taking an antacid."

D

D) "I had chickenpox and am immune to it, so my baby will not need to have the chickenpox vaccine."

D

D) "Weigh yourself daily while wearing the same amount of clothing."

D

D) Administer naloxone (Narcan).

D

D) Apply cool packs to the client's axillae and groin

D

D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.

D

D) Assess the client for other signs of infection.

D

D) Assess turgor on the client's forehead.

D

D) Basic infection control techniques

D

D) Change the dressing every 6 hours around the clock.

D

D) Check oxygen saturation and notify the health care provider.

D

D) Educate the client to sit on the side of the bed for a few minutes before rising.

D

D) Impaired proprioception

D

D) Obtain orders for a chest x-ray to confirm placement before starting the feeding.

D

D) Physical agility

D

D) Prioritization and administration of nursing care throughout the day

D

D) Providing assistance to the client in getting out of the bed or chair

D

D) Spontaneous ecchymosis

D

D) The client has bilateral dependent leg edema.

D

D) increasing global diversity.

D

D) is monitored by vital signs and capillary refill."

D

D) low birth weight.

D

D) nociceptive pain.

D

D) political views.

D

D) technology.

D

D) what specific type of pathogen is causing an infection.

D

d. I will weigh myself each morning before I eat or drink.

D

d. older clients have a different pain mechanism and do not feel it as much

D

d. social security as the basis of income

D

d. stop the IV infusion

D

The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan).

D A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? A) Agraphia B) Aphasia C) Impaired olfaction D) Impaired proprioception

D A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write.

What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? A) Requesting that a family member remain with the client to assist in ambulation B) Keeping all four siderails up while the client is in bed C) Placing the client in restraints to prevent movement without assistance D) Providing assistance to the client in getting out of the bed or chair

D Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point.

When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family. A) development. B) function. C) structure. D) political views.

D An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? A) "Avoid using aspirin-containing products." B) "Take your medication with food." C) "Check your pulse daily." D) "Avoid using salt substitutes."

D Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention? A) Place the client in Trendelenburg position to facilitate blood flow to the heart. B) Take the client's apical pulse for 1 full minute before drug administration. C) Instruct the client to drink 3 L of fluid daily when taking this medication. D) Educate the client to sit on the side of the bed for a few minutes before rising.

D Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a few minutes to prevent hypotension-induced falls. No indication is known for assessment of the apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg position is not indicated. In case of a precipitous drop in blood pressure, a modified Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in this situation.

A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? a. I will use a salt substitute when making and eating my meals. b. I must drink a quart of water or other liquid each day. c. I will not drink liquids after 6 PM so I won't have to get up at night. d. I will weigh myself each morning before I eat or drink.

D Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate? A) Document the findings and continue to monitor. B) Assess the client's pain level and treat if needed. C) Perform a Mini-Mental Status Examination. D) Assess the client for other signs of infection.

D Because of an age-related decline in immune function, an older adult's normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? A) "Eat six small meals daily instead of three larger meals." B) "When you feel short of breath, take an additional diuretic." C) "Avoid drinking more than 3 quarts of liquids each day." D) "Weigh yourself daily while wearing the same amount of clothing."

D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? A) New-onset confusion B) Repeated syncope C) Abdominal distention D) Spontaneous ecchymosis

D Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention.

The emphasis on understanding cultural influence on health care is important because of: A) disability entitlements. B) HIPAA requirements. C) litigious society. D) increasing global diversity.

D Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse's best action? A) Increase oxygen flow to 10 L/min. B) Perform an arterial blood gas analysis. C) Have the client cough and deep breathe. D) Check oxygen saturation and notify the health care provider.

D Decreased lung sounds and decreased lung expansion could indicate the development of a complication such as empyema or pus in the pleural space. The nurse should check the client's oxygen saturation and notify the provider. Infection can also move into the bloodstream and result in sepsis, so quick treatment is needed.

The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? A) "Increase your intake of foods high in potassium." B) "Avoid taking aspirin or aspirin-containing products." C) "Hold this medication if your pulse rate is below 80 beats/min." D) "Do not take this medication within 1 hour of taking an antacid."

D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.

The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is: A) large for gestational age. B) well nourished. C) born at term. D) low birth weight.

D Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain.

D Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider benefits d. social security as the basis of income

D Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? A) Completing all nursing care in the evening when the patient is more rested B) Completing all nursing care in the morning so the patient can rest the remainder of the day C) Limiting visitors, thus promoting the maximal amount of hours for sleep D) Prioritization and administration of nursing care throughout the day

D Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. This test will identify: A) what cells are being utilized by the body to attack an infection. B) whether a patient has an infection. C) where an infection is located. D) what specific type of pathogen is causing an infection.

D People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility

D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. assess for a blood return b. notify the physician c. document the finding d. stop the IV infusion

D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? A) Examine dependent body areas. B) Notify the physician. C) Document the finding and continue to monitor. D) Assess turgor on the client's forehead.

D Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

An older adult client is in physical restraints. Which intervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.

D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints.

The nurse is teaching a client who has recently given birth about immunity that has been passed to the newborn. Which statement by the client indicates that additional teaching is needed? A) "My baby received some antibodies from me before birth, and I will give him more when I breast-feed." B) "I had the measles, so my baby will be protected against it until he is old enough to receive the MMR vaccine." C) "Only certain antibodies were able to cross the placenta to protect my baby." D) "I had chickenpox and am immune to it, so my baby will not need to have the chickenpox vaccine."

D The baby receives passive immunity from antibodies that are passed through the placenta in utero. Maternal passive immunity is temporary and will last for only a short time after birth.

A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, "Perfusion A) is a normal function of the body, and I don't have to be concerned about it." B) varies as a person ages, so I would expect changes in the body." C) is monitored by the physician, and I just follow orders." D) is monitored by vital signs and capillary refill."

D The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first? A) The client's anterior-posterior chest diameter is 2:2. B) Clubbing of the finger tips is noted. C) The client is pale. D) The client has bilateral dependent leg edema.

D The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention.

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include: A) adherence. B) developmental level. C) motivation. D) technology.

D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse? A) Start the tube feeding as ordered and check the residual in 30 minutes. B) Inject air into the nasogastric tube while auscultating the client's epigastric area. C) Lower the head of the client's bed and attempt to aspirate fluid again. D) Obtain orders for a chest x-ray to confirm placement before starting the feeding.

D The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client's head elevated at least 30 degrees.

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? A) Limiting contact with the general population B) The importance of wearing a face mask in public C) The mechanisms of the inflammatory response D) Basic infection control techniques

D The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST? A) Obtaining a fan from central supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin

D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate.

Which statement made by a nurse represents the need for further education regarding pain management in older adult clients? a. older adults tend to report pain less often than younger adults b. older clients usually have more experience with pain than younger clients c. older adults are at greatest risk for under treated pain d. older clients have a different pain mechanism and do not feel it as much

D There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The other statements are accurate regarding older clients and pain.

A client has a deep wound covered with a wet-to-damp dressing. Which intervention does the nurse include on this client's care plan? A) Apply a new dressing when the seal breaks and the dressing leaks. B) Change the dressing when the current dressing is saturated. C) Leave the dressing intact until next week. D) Change the dressing every 6 hours around the clock.

D Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings should be changed when the outer layer becomes saturated.

Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia.

D) Global aphasia.

C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessing, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

During assessment of a client with a 15-year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first? A) Notify the health care provider. B) Document the finding in the client's chart. C) Examine the client's feet for signs of injury. D) Test sensory perception in the client's hands.

D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility

B.

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. Rub the client's feet briskly for several minutes. B. Obtain a pair of slipper socks for the client. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet.

Answer: (C) "With a pillow, apply pressure against the incision." Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.

Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse's best response would be: A. "Pain will become less each day." B. "This is a normal reaction after surgery." C. "With a pillow, apply pressure against the incision." D. "I will give you the pain medication the physician ordered."

D People can transmit pathogens even if they don't currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight an infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. This test will identify: A) what cells are being utilized by the body to attack an infection. B) whether a patient has an infection. C) where an infection is located. D) what specific type of pathogen is causing an infection.

A, B, D Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection.

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) A) High cost of medications B) Inadequate nutrition C) Easy access to health screenings D) Uninsured or underinsured status

D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include: A) adherence. B) developmental level. C) motivation. D) technology.

Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.

Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse's best A. The patient is having an allergic reaction to the drug. B. The patient needs a higher dose of this drug C. This is normal side-effect of AtSO4 D. The patient is anxious about upcoming surgery

Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?" The client is showing signs of anxiety reaction to a stressful event. Recognizing the client's anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.

Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach? A. "Good evening, Mr. Pablo. Wasn't it a pleasant day, today?" B. "Mr, Pablo, you must be so worried, I'll leave you alone with your thoughts. C. "Mr. Pablo, you'll wear out the hospital floors and yourself at this rate." D. "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?"

C Sucking up here with C may be dependent on how low your accumulative test scores are...

O-H- A) who cares! B) I cannot pick this so I will lose points (this is for the Michigan Fans!!) C) I-O D) O-No!!

C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician.

The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehydrated client. C) Use sterile technique when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%.

B It is important for the nurse to assess respirations of the client when administering opioids because of the possibility of respiratory depression. The other interventions may or may not be necessary in the care of the client and do not focus on safety.

The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective? A) Performing range-of-motion exercises on the client three times each day B) Assessing the client's respirations when administering opioids C) Delegating to the nursing assistant to give the client a complete bath daily D) Ensuring that the client is eating 100% of the meals served to him or her

D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. assess for a blood return b. notify the physician c. document the finding d. stop the IV infusion

C Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no further intervention is required.

The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first action? A) Administering oxygen by nasal cannula B) Documenting the findings and continuing to monitor C) Arousing the client by calling his or her name D) Administering naloxone (Narcan) IV push

C The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client.

The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals. D) Complete the nursing care plan.

C Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.

The client with type 2 diabetes has recently been changed from the oral antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to glyburide-metformin (Glucovance). The nurse includes which information in the teaching about this medication? A) "Glucovance is more effective than glyburide and metformin." B) "Your diabetes is improving and you now need only one drug." C) "Glucovance contains a combination of glyburide and metformin." D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents."

A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be: A) change in level of consciousness. B) unequal pupil size. C) loss of primitive reflexes. D) inability to focus visually.

D Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

The emphasis on understanding cultural influence on health care is important because of: A) disability entitlements. B) HIPAA requirements. C) litigious society. D) increasing global diversity.

C Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client's heparin can be safely discontinued. Effects of heparin will be cleared from the client's bloodstream within a few hours.

The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action? A) Turn off the heparin before administering the warfarin. B) Clarify the warfarin order with the nursing supervisor. C) Administer both heparin and warfarin as prescribed. D) Hold the warfarin dose until the heparin is discontinued.

A The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) A) rectal thermometer. B) tympanic membrane sensor. C) temporal thermometer scan. D) oral thermometer.

D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate.

The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST? A) Obtaining a fan from central supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin

D A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.

The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan).

A NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.

The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time does the nurse assess the client for problems related to the NPH insulin? A) 4 PM B) 11 PM C) 8 AM D) 8 PM

B With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates: A) slow capillary refill. B) red, sweaty skin. C) low pulse rate. D) decreased respirations.

D Decreased lung sounds and decreased lung expansion could indicate the development of a complication such as empyema or pus in the pleural space. The nurse should check the client's oxygen saturation and notify the provider. Infection can also move into the bloodstream and result in sepsis, so quick treatment is needed.

The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse's best action? A) Increase oxygen flow to 10 L/min. B) Perform an arterial blood gas analysis. C) Have the client cough and deep breathe. D) Check oxygen saturation and notify the health care provider.

B Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain may be present with activity and at rest. Edema and ankle discoloration would be indicative of venous insufficiency.

The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency? A) Pain with activity but not while resting B) Dependent mottling and absence of hair C) Full veins present in dependent extremity D) Ankle discoloration and pitting edema

B Basophils and eosinophils release histamine, kinins, and other substances that cause the manifestations of inflammation. Erythrocytes carry oxygen, and platelets help stop bleeding. Plasma cells and B-lymphocytes produce antibodies to help fight infection, and natural killer cells destroy invading bacteria.

The nurse assesses a cut that is 24 hours old and finds that the site is swollen, red, and tender to the touch. Which cell types are responsible for these assessment findings? A) Natural killer cells B) Basophils and eosinophils C) Erythrocytes and platelets D) Plasma cells and B-lymphocytes

D A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write.

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? A) Agraphia B) Aphasia C) Impaired olfaction D) Impaired proprioception

A,B,D Systemic manifestations of inflammatory response include elevated temperature, leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered local manifestations of inflammation.

The nurse assesses the patient and notes all of the following. Select all of the findings that indicate the systemic manifestations of inflammation. A) Oral temperature 38.6 F B) WBC 20 C) Thick, green nasal discharge D) Patient reports, "I'm tired all the time. I haven't felt like myself in days" E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary sinuses

B The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed by using an incentive spirometer. If no spirometer is available, coughing and deep breathing is the next best option. This client does not have wheezing, so bronchodilators are not indicated. IV fluids would not help atelectasis.

The nurse auscultates the following lung sound in the client with pneumonia. What is the best intervention? Audio Clip A) Administer IV fluids. B) Have the client use an incentive spirometer. C) Have the client cough and deep breathe. D) Prepare to administer a bronchodilator.

B A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protection measures than are currently provided.

The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention related to this assessment? A) Increase the client's fluid intake. B) Consult with the health care provider. C) Reassess the client in 3 days. D) Document the finding per protocol.

C One expected outcome for a client with hypertension is for the client to have no evidence of target organ damage, such as renal or heart disease, that can occur with poorly managed hypertension. Development of pedal edema is not directly related to the management of hypertension. Side effects of some hypertensive agents may interfere with sexual function, but this does not relate to the effectiveness of treatment for hypertension. The blood pressure reading is too high to demonstrate effective management.

The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management? A) No complaints of sexual dysfunction occur. B) Pedal edema is not present in the lower legs. C) No indication of renal impairment is present. D) The blood pressure reading is 148/94 mm Hg.

B A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? A) KCl 20 mEq PO two times per day B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr C) Oxygen via face mask at 8 L/min D) Furosemide (Lasix) 20 mg PO now

C Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? A) "I sleep with four pillows at night." B) "I wake up coughing every night." C) "My shoes fit really tight lately." D) "I have trouble catching my breath."

C A client who undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the catheter is removed. However, the presence of bright red blood with clots indicates arterial bleeding and should be reported to the provider.

The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse? A) Having the urge to void continuously while the catheter is inserted B) Passing small blood clots after catheter removal C) Having bright red drainage with multiple blood clots D) Experiencing urinary frequency after catheter removal

A Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by peripheral arterial disease are painful and initially are located at the most distal points on the extremity. Diabetic ulcers and venous ulcers are seldom painful and usually tend to occur where pressure is applied.

The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with? A) Peripheral arterial disease B) Deep vein thrombosis C) Diabetic foot ulceration D) Peripheral venous disease

C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out.

The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication.

A Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS.

The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestations does the nurse expect to see? A) Nystagmus & Diplopia B) Hyperresponsive reflexes C) Excessive somnolence D) Heat intolerance

A,B,D,E Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) A) S3/S4 summation gallop B) Cough worsens at night C) Dependent edema D) Pulmonary crackles E) Confusion, restlessness F) Pulmonary hypertension

D The client with bilateral dependent edema may be developing right-sided heart failure in response to respiratory disease. This symptom should be investigated right away and reported to the health care provider. Further assessment is needed. The client with chronic lung disease may develop increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These symptoms do not require immediate intervention. The client is often pale or has a dusky appearance; this also would not warrant immediate intervention.

The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for first? A) The client's anterior-posterior chest diameter is 2:2. B) Clubbing of the finger tips is noted. C) The client is pale. D) The client has bilateral dependent leg edema.

A,D,E,F Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection.

The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.) A) Redness B) Fever C) Increased erythrocyte sedimentation rate (ESR) D) Pain E) Swelling F) Warmth

A Compliance with antihypertensive therapy is difficult for two reasons. First, often clients have no distressing symptoms associated with hypertension and may not believe that they have a problem. Second, many clients believe that once blood pressure is brought back into the normal range, they are "cured" and no longer need to take medication. Losing weight might allow the client to reduce medications. Lowering blood pressure does lower risk for heart attack. Because blood pressure medications often lead to orthostatic hypotension, clients should be taught to change position slowly, sitting first before standing after lying flat.

The nurse is assessing a client's understanding of his hypertension therapy. What client statement indicates a need for further teaching? A) "When my blood pressure is normal, I will no longer need to take medication." B) "If my blood pressure stays under control, I will reduce my risk for a heart attack." C) "If I lose weight, I might be able to reduce my blood pressure medication." D) "When getting out of bed in the morning, I will sit for a few moments then stand."

C, D, E, F clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.

The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (select all that apply) a. an older woman with hypertension b. a young man with a body mass index of 42 c. a young many who has just consumed six martinis d. an older man who smokes a pack of cigarettes a day e. a young woman who is anorexic f. a young woman who is diabetic

A,B,F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) A) There is presence of quiet, effortless breath sounds at lung base bilaterally. B) Nail beds are pink with good capillary refill. C) Trachea is just to the left of the sternal notch. D) Respiratory rate is 24 breaths/min. E) The right side of the thorax expands slightly more than the left. F) Oxygen saturation level is 98%.

C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? A) Healthy individual, college educated, travels frequently, can balance a checkbook B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volunteers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed

A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? A) Middle-aged woman with aortic stenosis B) Older woman who smokes cigarettes daily C) Older man who has had a myocardial infarction D) Middle-aged man with pulmonary hypertension

A The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient: A) with a hemoglobin of 8.5 g/dL B) with a blood glucose of 350 mg/dL C) who has been on anticoagulants for 10 days D) with a heart rate of 100 beats/min and blood pressure of 100/60

B Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.

The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy

B Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours.

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? A) Position with the head of the bed flat to enhance cerebral perfusion. B) Monitor neurologic and vital signs closely to identify early changes in status. C) Administer prescribed analgesics to promote pain relief. D) Cluster nursing procedures together to avoid fatiguing the client.

A Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids.

The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? A) Place the client in high Fowler's position. B) Verbalize the placement of food on the client's plate. C) Order a clear liquid diet for the client. D) Turn the client's plate around halfway through the meal.

C For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? A) Turn on the television to a 24-hour news station. B) Provide auditory and visual stimulation simultaneously. C) Ask the family to bring in pictures familiar to the client. D) Maintain a calm and quite environment by minimizing visitors.

B,D Protamine sulfate is the antidote for heparin-induced bleeding. Vitamin K is the antidote for warfarin. Warfarin (Coumadin) would increase bleeding. Enoxaparin is another name for heparin.

The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.) A) Laboratory draw for prothrombin time (PT)/international normalized ratio (INR) B) Laboratory draw for activated partial thromboplastin time (aPTT) C) Administer enoxaparin (Lovenox) D) Administer protamine sulfate E) Administer vitamin K

B To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility.

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? A) Teach the client to touch and use both sides of the body. B) Apply sequential compression stockings. C) Instruct the client to turn the head from side to side. D) Position the client with the unaffected side down.

C Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.

The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time? A) 30 seconds B) 150 seconds C) 60 seconds D) 15 seconds

B The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease.

The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? A) Traces of blood in the stool B) Distended abdomen C) Temperature of 100.0° F (37.8° C) D) Crampy lower abdominal pain

C The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? A) Position the client to allow gravity drainage of the fistula. B) Check and record blood glucose levels every 6 hours. C) Encourage the client to consume a diet high in protein and calories. D) Monitor the client's hematocrit and hemoglobin.

B Smoking causes vasoconstriction, and its effects can last up to 1 hour after the cigarette is finished. Increasing activity may lead to collateral circulation but does not cause vasodilation. Use of a heating pad is contraindicated in the client with peripheral artery disease because of the risk of a burn caused by diminished sensation. The use of aspirin my impede platelet clumping and is contraindicated only when the client is on anticoagulants.

The nurse is caring for a client with peripheral arterial disease. What priority nursing intervention does the nurse perform to promote vasodilation? A) Increase the client's exercise regimen daily. B) Educate the client to abstain from smoking. C) Apply a heating pad to the affected limb. D) Administer an aspirin on a daily basis.

C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? A) Skin integrity B) Blood pressure C) Heart rate and rhythm D) Abdominal percussion

A The client's body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight.

The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? A) "No. In fact, your body mass index suggests that you are already underweight." B) "Yes. Your body mass index suggests you are slightly overweight." C) "Your weight is just fine. Don't worry about it." D) "Maybe. Let's look at your risks for cardiovascular disease."

D The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenectomy does not need to understand the mechanisms of inflammatory response. The patient with a splenectomy does not need to wear a face mask in public as long as the patient understands and maintains the basic principles of infection control. The patient who has had a splenectomy does not need to limit contact with the general population as long as the patient understands and maintains the basic principles of infection control.

The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning? A) Limiting contact with the general population B) The importance of wearing a face mask in public C) The mechanisms of the inflammatory response D) Basic infection control techniques

C The prealbumin level is a good measure of nutritional status because its half-life is only 2 days, so it reflects current nutritional status. The client's prealbumin level is rising and almost normal, indicating that the client's nutritional status is improving. The other laboratory values are more reflective of fluid balance and kidney function.

The nurse is caring for an anorexic client who is severely malnourished. A nasogastric feeding tube is inserted, and tube feedings are started. Which laboratory finding is the best indication that the client's nutritional status is improving? A) Creatinine has dropped from 1.9 to 0.5 mg/dL. B) Blood urea nitrogen (BUN) level has dropped from 15 to 11 mg/dL. C) Prealbumin level has risen from 9 to 13 mg/dL. D) Sodium has risen from 130 to 144 mg/dL.

A Older adult clients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in mental status in the older postoperative client should lead the nurse to assess for a wound infection.

The nurse is caring for an older postoperative client. Which assessment finding causes the nurse to assess further for a wound infection? A) The client is now confused but was not confused previously. B) Moderate serosanguineous drainage is seen on the dressing. C) The white blood cell count is 8000/mm3. D) The white blood cell differential indicates a right shift.

D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.

The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? A) "Increase your intake of foods high in potassium." B) "Avoid taking aspirin or aspirin-containing products." C) "Hold this medication if your pulse rate is below 80 beats/min." D) "Do not take this medication within 1 hour of taking an antacid."

B Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism, predisposing the client to obesity when taken on a long-term basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric upset and ulceration and decreased appetite and weight loss. The client's glycosylated hemoglobin and thyroid levels are within normal limits and would not explain the hunger and weight gain.

The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks. The client states that she is hungry all the time and doesn't understand why. Which assessment finding could explain the client's weight gain and hunger? A) The client's glycosylated hemoglobin level is 6%. B) The client started taking dexamethasone (Decadron) daily. C) The client started taking naproxen sodium (Naprosyn) daily. D) The client's thyroxine (T4) level is 8 mcg/dL.

B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.

The nurse is caring for four clients. Which client assessment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision

B As with any anticoagulation, low-molecular-weight heparin incurs risk of bleeding. Clients should be taught to report to their health care provider the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae. Low-molecular-weight heparin does not affect activated partial thromboplastin time (aPTT), as does intravenous heparin. This type of heparin is administered subcutaneously to deliver a slow sustained response. Massaging the site would hasten absorption and decrease effects.

The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client? A) "You must have your aPTT checked every 2 weeks." B) "Notify your health care provider if your stools appear tarry." C) "An IV catheter will be placed to administer your heparin." D) "Massage the injection site after the heparin is injected."

C The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to: A) bathe and dry the skin vigorously to stimulate circulation. B) limit intake of fluid and offer frequent snacks. C) turn the patient at least every 2 hours. D) keep the head of the bed elevated 30 degrees.

B Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis). The other statements are not accurate descriptions of the actions of glucagon.

The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? A) It enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. B) It prevents hypoglycemia by promoting release of glucose from liver storage sites. C) It is a storage form of glucose and can be broken down for energy when blood glucose levels are low. D) It converts excess glucose into glycogen, lowering blood glucose levels in times of excess.

B All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction.

The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important? A) Double check the "five rights." B) Assess the client for allergies. C) Teach the client about the drug. D) Check the IV for patency.

D The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client's head elevated at least 30 degrees.

The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse? A) Start the tube feeding as ordered and check the residual in 30 minutes. B) Inject air into the nasogastric tube while auscultating the client's epigastric area. C) Lower the head of the client's bed and attempt to aspirate fluid again. D) Obtain orders for a chest x-ray to confirm placement before starting the feeding.

B,C,D A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.) A) Use a rubber ring to decrease sacral pressure when up in the chair. B) Place a small pillow between bony surfaces. C) Keep the heels off the bed surfaces. D) Use a lift sheet to assist with repositioning. E) Reposition the client who is in a chair every 2 hours. F) Elevate the head of the bed to 45 degrees. G) Limit fluids and proteins in the diet.

D The baby receives passive immunity from antibodies that are passed through the placenta in utero. Maternal passive immunity is temporary and will last for only a short time after birth.

The nurse is teaching a client who has recently given birth about immunity that has been passed to the newborn. Which statement by the client indicates that additional teaching is needed? A) "My baby received some antibodies from me before birth, and I will give him more when I breast-feed." B) "I had the measles, so my baby will be protected against it until he is old enough to receive the MMR vaccine." C) "Only certain antibodies were able to cross the placenta to protect my baby." D) "I had chickenpox and am immune to it, so my baby will not need to have the chickenpox vaccine."

B Increasing fluids has been proven to decrease the thickness of secretions, thus allowing them to be expectorated quickly. The other interventions would not be as effective.

The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective? A) Administering an antiemetic medication B) Increasing fluids to 2 L/day if tolerated C) Administering an antitussive medication D) Having the client cough and deep breathe hourly

C The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse? a. admin tylenol 650 mg orally b. encourage rest, and reassess in 15 minutes c. sponge the victim with cool water and remove his shirt d. encourage drinking of cool water or sports drink

A Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a: A) portal of entry. B) host. C) mode of transmission. D) reservoir.

B, E, F The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) A) Endocrine system B) Neurologic system C) Hepatic system D) Immune system E) Cardiovascular system F) Pulmonary system

D Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is: A) large for gestational age. B) well nourished. C) born at term. D) low birth weight.

Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.

The nurse needs to carefully assess the complaint of pain of the elderly because older people A. are expected to experience chronic pain B. have a decreased pain threshold C. experience reduced sensory perception D. have altered mental function

C Venous ulcers are characterized by brown pigmentation of the skin of the lower extremity. Mottled skin, the presence of dependent rubor, and cyanosis are features of arterial ulcers.

The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client? A) Absence of hair on the left lower extremity B) Skin surrounding the ulcer mottled but blanchable C) Brownish discoloration of the lower extremity D) Cold and gray-blue lower extremity

A In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement.

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. assess the client's respiratory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure d. call the health care provider

A This "hidden" wound may first be observed as a small opening in the skin through which purulent drainage exudes. Applying a transparent film dressing would not help this type of wound to heal. Measuring the reddened area would not assist in determining the actual size of the wound, because internal damage has occurred. Alginate dressings could not be applied if the area were not opened.

The nurse observes a small opening that is draining purulent material on the skin over the trochanter area of a bedridden client. Which is the nurse's next best action? A) Probe for a larger pocket of necrotic tissue. B) Apply alginate dressing daily. C) Apply a transparent film dressing. D) Measure the reddened area on the skin surface.

D Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? A) Examine dependent body areas. B) Notify the physician. C) Document the finding and continue to monitor. D) Assess turgor on the client's forehead.

B,C,D,F,G

The nurse prepares to teach a patient recovering from a myocardial infarction (MI) about combination durg therapy based on "best practice" for controlling hypertension. Which drugs does the nurse include in the teaching plan? SELECT ALL THAT APPLY!!! A) NSAID's B) Aspirin C) Aldosterone antagonists D) ACE Inhibitors or ARB's E) Central alpha Agonists F) Beta Blockers G) Diuretics

C Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? A) Examine sacral area and patient's heels for skin breakdown due to potential edema. B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures. C) Institute fall precautions due to potential postural hypotension and weak leg muscles. D) Raise bed side rails due to potential decreased level of consciousness and confusion.

B

The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient? A) 8 mL B) 7.5 mL C) 7 mL D) 5.5 mL

C 60/40 (desired/have)

The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/2 d. 2 1/5

B The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

The priority nursing intervention for a patient suspected to be hypothermic would be to: A) hydrate with intravenous (IV) fluids. B) remove wet clothes. C) assess vital signs. D) provide a warm blanket.

D Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain.

C, E, G Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition.

What information about nutrition does the nurse teach a client with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) A) "Eat dry foods rather than wet foods, which are heavier." B) "Increase carbohydrate intake for energy." C) "Have about six small meals a day." D) "Practice diaphragmatic breathing against resistance four times daily." E) "Avoid drinking fluids just before and during meals." F) "Eat high-fiber foods to promote gastric emptying." G) "Rest before meals if you have dyspnea."

A The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

What interrelated constructs facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge

D Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point.

What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? A) Requesting that a family member remain with the client to assist in ambulation B) Keeping all four siderails up while the client is in bed C) Placing the client in restraints to prevent movement without assistance D) Providing assistance to the client in getting out of the bed or chair

C Seriously, if you don't know the instructor's favorite football by this time, you need to listen to your recordings from the first lecture. Just sayin'

What is my favorite football team? A) I hate football!! B) the Fightin' Irish C) GO BUCKS!!!! D) that team up north

A Bone marrow suppression leads to neutropenia and increases the client's risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.

What statement indicates that the client understands teaching about neutropenia? A) "I will call my doctor if I have an increase in temperature." B) "My grandchildren may get an infection from me." C) "I need to use a soft toothbrush." D) "I have to wear a mask at all times."

A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred.

When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility

C The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? A) "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." B) "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis." C) "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." D) "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity."

C,D,E,F Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patient's preferences for toileting. They are personal preferences and do not affect elimination.

When conducting a health history assessment, the nurse would want to know what important information about the patient's elimination status? (Select all that apply.) A) Time of day patient defecates B) Patient's preferences for toileting C) List of medications taken by patient D) Recent changes in elimination patterns E) Changes in color, consistency, or odor of stool or urine F) Discomfort or pain with elimination

C. Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. follows formalized plans b. has standardized content c. often occurs one-to-one d. addresses group needs

A,B,E,F Many factors contribute to malnutrition in older clients. Depression and loneliness from the loss of a spouse; constipation; poor eyesight; chronic medical problems, including depression; and taking prescription and/or over-the-counter medications can contribute to malnutrition. Blood glucose levels and a previous cholecystectomy would not necessarily contribute.

When reviewing an older client's medical record, which findings lead the nurse to perform a nutrition assessment? (Select all that apply.) A) Widow/widower status B) Chronic constipation C) Cholecystectomy 4 years ago D) Random blood sugar level of 198 mg/dL E) History of depression F) Inability to afford a new pair of glasses

D An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family. A) development. B) function. C) structure. D) political views.

C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client's status after a medication change would not be considered activities of the Rapid Response Team.

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? A) Documenting all changes observed in the client and maintaining a postoperative flow sheet B) Monitoring the client for changes in postoperative status such as wound infection C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic D) Notifying the physician of the client's increase in restlessness after medication change

B Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.

Which action does the nurse teach a client to reduce the risk for dehydration? A) Avoiding the use of glycerin suppositories to manage constipation B) Maintaining a daily oral intake approximately equal to daily fluid loss C) Restricting sodium intake to no greater than 4 g/day D) Maintaining an oral intake of at least 1500 mL/day

B Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. Clients with pneumonia and hypertension do not have specific risk factors. The client who needs assistance with ambulation might be at moderate risk if he or she does not move about much, but having two risk factors makes the last option the person at highest risk.

Which client does the nurse assess to be at greatest risk for pressure ulcer development? A) Client who requires assistance with ambulation B) Incontinent client with limited mobility C) Client with hypertension on multiple medications D) Client who has pneumonia

C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration

Which client is at greatest risk for dehydration? a. younger adult client on bedrest b. older adult client receiving hypotonic IV fluid c. older adult client with cognitive impairment d. younger adult client receiving hypertonic IV fluid

C Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a portal for organisms to enter the body and cause infection.

Which client is at highest risk of compromised immunity? A) Client with extreme anxiety B) Client who is awaiting surgery C) Client who has just had surgery D) Client who just delivered a baby

A Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client.

Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections? A) "Even if I feel completely well, I should take the medication until it is gone." B) "When my urine no longer burns, I will no longer need to take the antibiotics." C) "If my urine becomes lighter and clearer, I can stop taking my medicine." D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."

C A compromised immune system puts a client at greatest risk for infection. Although all the other options might increase the client's susceptibility, the one with the greatest potential impact is being immune compromised.

Which finding puts a client at greatest risk for wound infection? A) Presence of a deep wound B) Coexisting medical conditions C) Immune compromised status D) Severely reddened skin

A Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position d. Measuring intake and output every four hours

A,B,C,E

Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? SELECT ALL THAT APPLY!! A) check the residual volume every 4-6 hours B) use clean technique when changing the feeding system C) keep the head of the beg elevated at least 30 degrees D) change the feeding bag & tubing every 12 hours E) allow closed system containers to hang for 24 hours

A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations.

Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pressure C) Crying D) Decreased respirations E) Facial grimace F) Restlessness

A Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation.

Which is the highest priority goal to set for a client with pneumonia? A) Maintenance of SaO2 of 95% B) Walking 20 feet three times daily C) Absence of cyanosis D) Absence of confusion

A Friction forces are generated when the client is dragged or pulled across bed linen; this often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an important intervention, but powders should not be used in the perineal area. To minimize vasoconstriction and possible pressure ulcer development from dependency, the client should be turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to an area.

Which nursing intervention best assists a bedridden client to keep skin intact? A) Use a lift sheet to move the client in bed. B) Turn the client every 2 to 4 hours. C) Use a foam mattress pad. D) Apply talcum powder to the perineal area.

C,D,F When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) A) Constricted pupils B) Flushed skin C) Tremors D) Nervousness E) Extreme thirst F) Profuse perspiration

C Although age is a factor in the development of community-acquired pneumonia, other lifestyle and exposure factors increase the risk to a greater extent than age. Two conditions that heavily predispose to the development of pneumonia are cigarette smoking and alcoholism. Dietary choices typically do not predispose to the development of pneumonia. Cigarette smoking interferes with the ciliary function of removal of invasive materials. Alcoholism usually results in unbalanced nutrition, as well as decreased immune function. A middle-aged adult, an older adult with wheezing induced by exercise, and a young adult vegetarian would not be at risk for community-acquired pneumonia because they have no predisposing conditions.

Which person is at greatest risk for developing a community-acquired pneumonia? A) Young adult aerobics instructor who is a vegetarian B) Middle-aged teacher who typically eats a diet of Asian foods C) Older adult who smokes and has a substance abuse problem D) Older adult with exercise-induced wheezing

A Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the amount of vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to warfarin.

Which statement by a patient indicates additional teaching is required about the medication warfarin? A) "I will increase the intake of green, leafy vegetables for a more healthful diet." B) "I will restrict the intake of foods high in vitamin C." C) "I will increase the amount of protein in my diet to protect my kidneys." D) "I will continue my diabetic diet and restrict sugar."

C Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis.

Which statement indicates that the client needs more teaching about mucositis? A) "I will use a soft-bristled toothbrush to prevent trauma." B) "I will rinse my mouth with water after every meal." C) "I should use an alcohol-based mouth rinse to kill bacteria." D) "I cannot use floss because it may irritate my gums."

D There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The other statements are accurate regarding older clients and pain.

Which statement made by a nurse represents the need for further education regarding pain management in older adult clients? a. older adults tend to report pain less often than younger adults b. older clients usually have more experience with pain than younger clients c. older adults are at greatest risk for under treated pain d. older clients have a different pain mechanism and do not feel it as much

D Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? A) Completing all nursing care in the evening when the patient is more rested B) Completing all nursing care in the morning so the patient can rest the remainder of the day C) Limiting visitors, thus promoting the maximal amount of hours for sleep D) Prioritization and administration of nursing care throughout the day

B Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.

Why does the nurse always ask the client his or her pain level after taking routine vital signs? A) To follow McCaffery's guidelines on pain management B) To ensure that pain assessment occurs on a regular basis C) To determine the need for more frequent vital sign measurement D) To determine whether pain is influencing blood pressure and heart rate

During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond? a. Ask for a demonstration of these exercises b. Explain that coughing should be avoided c. Review the client previous surgical history d. Document the clients understanding of teaching

a. Ask for a demonstration of these exercises

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Eating patterns and dietary intake b. Level and amount of physical activity c. Color and consistency of feces d. Presence and activity of bowel sounds

a. Eating patterns and dietary intake

The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease? a. Large waist circumference with central fat b. High serum insulin level c. Hyperpigmentation on neck skin folds d. Poor muscle tone

a. Large waist circumference with central fat

The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? a. Manual dexterity and visual acuity b. Capillary refill time and radial pulse volume c. Deep tendon reflexes and skin color d. Skin elasticity and hand grip strength.

a. Manual dexterity and visual acuity

Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement? a. Patch one eye and then the other every few hours b. Encourage bedrest until the diplopia is resolved c. Instruct the client to limit intake of oral fluids d. Administer artificial tear drops to both eyes

a. Patch one eye and then the other every few hours

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Schedule an appointment or the client to see the healthcare provider b. Advise the client to apply plastic wrap over the ointment to promote healing c. Instruct the client to continue the ointment until all erythema is relieved d. Explain the client need to complete all prescribed dose of the medication

a. Schedule an appointment or the client to see the healthcare provider

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium of 185 mEq/L b. Dry skin with inelastic turgor c. Apical rate of 110 beats/minute d. Polyuria and excessive thirst

a. Serum sodium of 185 mEq/L

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? a. Teach the client to elevate the head of the bed on blocks b. Remind the client to avoid high-fiber foods c. Encourage the client to lie down and rest after meals. d. Instruct the client to use antacids only as a last resort

a. Teach the client to elevate the head of the bed on blocks

A male client who reports feeling chronically fatigued has a Hgb of 11.0 grams/dl, hematocrit of 34%, and microcytic and hypochromic red blood cells. Based on these findings, which dinner selection should the nurse suggest to the client? a) cheese pasta and a lettuce and tomato salad b) beef steak with steamed broccoli and orange slices c) broiled white fish with a baked sweet potato d) grilled shrimp and seasoned rice with asparagus salad

b) beef steak with steamed broccoli and orange slices

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the HCP? a) slight blood-tinged sputum b) dyspnea and dysphagia c) sore throat and hoarseness d) no gag reflex after thirty minutes

b) dyspnea and dysphagia

A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic? a. Elasticity of the skin b. Appearance of any moles c. Muscle aches and pains d. Pigmentation of the skin

b. Appearance of any moles

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? a. Cheese pasta and a lettuce and tomato salad b. Beef steak with steamed broccoli and orange slices c. Broiled white fish with a baked sweet potato d. Grilled shrimp and season rice with asparagus salad

b. Beef steak with steamed broccoli and orange slices

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? a. Re-orient the client to his present location and circumstances b. Confirm that this is an effective technique to help with ambulation c. Assist the client to a carpeted area where he can walk more easily. Plan to assess the client's cognition after returning to his room.

b. Confirm that this is an effective technique to help with ambulation

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse. a. Strong foul-smelling flatus b. Gastroccult positive emesis c. Complaint of poor night vision d. Loose bowel movements

b. Gastroccult positive emesis

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? a. Provide assistive devices to empower client independence b. Implement measures to manage chronic pain c. Teach coping skills for living with a chronic illness d. Schedule rest periods between activates to minimize fatigue.

b. Implement measures to manage chronic pain

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? a. Black ulcers and dependent rubor b. Irregular ulcer shapes and severe edema c. Absent pedal pulses and shiny skin d. Hairless lower extremities and cool feet

b. Irregular ulcer shapes and sever edema

An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? a. IV pentamidine may offer protection to other AIDS-related conditions, such as Kaposi's sarcoma b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month c. IV pentamidine will be given until oral pentamidine can be tolerated d. AZT (Azidothymidine) therapy must be stopped when IV or aerosol pentamidine is being used.

b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? a. Glucose b. Platelet count c. White blood cell count d. Amylase

b. Platelet count

Two days following abdominal surgery a client c/o of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? a) encourage pt to ambulate b) offer ice chips or warm liquids c) auscultate abdomen d) assess temperature

c) Auscultate the client's abdomen

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? a. Elevate the hands on two pillows at night b. Notify the healthcare provider as soon as possible c. Wear braces as both wriSts during the night d. Apply cold compresses for 30 min before bedtime

c. Wear braces as both wriSts during the night

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which lab value is most important for the nurse to monitor following the procedure? a. Serum creatinine b. Blood urea nitrogen (BUN) c. White blood cell count d. Serum glucose

c. White blood cell count

A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first? a. Teach the client about the importance of hydration b. Report the volume of emesis t the healthcare provider c. Administer ondansetron hydrochloride (Zofran) Encourage the client to limit the amount of move

c. Administer ondansetron hydrochloride (Zofran)

Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first? a. Encourage the client to ambulate b. Offer ice ships or warm liquids c. Auscultate the client's abdomen d. Assess the client's temperature

c. Auscultate the client's abdomen

A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? a. Teach client to use pursed lip breathing when episodes occur b. Assess client for signs and symptoms of upper airway infection c. Determine if the client is using an inhaler before exercising d. Review the client's routine asthma management prescriptions.

c. Determine if the client is using an inhaler before exercising

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? a. Continuous cardiac monitoring b. Perform passive range of motion c. Evaluate level of consciousness d. Assess lung sounds q4 hours.

c. Evaluate level of consciousness

1. A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? a. Consult with surgeon about increasing methadone in lieu of parenteral opioids. b. Use minimal parenteral opioids for surgical pain, in addition to oral methadone c. Maintain client's methadone, and medicate surgical pain based on pain rating d. Make no changes in the standard pain management for the surgery and hold methadone.

c. Maintain client's methadone, and medicate surgical pain based on pain rating

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? a. Assist with ambulation in the hallway b. Encourage active range of motion exercises c. Provide a bedside commode for toileting d. Teach to sleep in a slide-laying position

c. Provide a bedside commode for toileting

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? a. Teach a family member to administer eye drops b. Encourage deep breathing and coughing exercises c. Provide an eye shield to be worn while sleeping d. Obtain vital signs every 2 hours during hospitalization

c. Provide an eye shield to be worn while sleeping

An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? a. Serum electrolytes b. Neutrophils and eosinophils c. Serum iron and ferritin d. Platelet count and hematocrit

c. Serum iron and ferritin

A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first a. Sevelamer (RenaGel) one tablet PO. b. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ c. Sodium polystyrene (Kayexalate) 15 grams PO d. Calcium acetate (Phos-Lo) one tablet PO

c. Sodium polystyrene (Kayexalate) 15 grams PO

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements? a. Hard pellets of stool b. Clay-colored stool c. Stool with fatty streaks d. Blood in the stool

c. Stool with fatty streaks

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation a. Low-sodium soups. b. Over all fluid intake c. Tea and hot chocolate d. Citrus fruit juices

c. Tea and hot chocolate

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) a. Initiate passive range of motion exercises b. Establish a regular bladder routine c. Teach the client breathing exercises d. Perform chest physiotherapy e. Encourage use of incentive spirometer

c. Teach the client breathing exercises e. Encourage use of incentive spirometer

1. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? a. Notify the healthcare provider b. Assure the client that such feelings occur with wound infections c. Visualize the abdominal incision d. Obtain sterile towels soaked in saline

c. Visualize the abdominal incision

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider? a. Slight blood-tinged sputum b. Dyspnea and dysphagia c. Sore throat and hoarseness d. No gag reflex after thirty minutes

d. No gag reflex after thirty minutes

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. Glucose of 350 mg/dl b. White blood cell count of 15, 000 mm3 c. Blood PH of 7.30 d. Potassium of 2.5 mEq/L

d. Potassium of 2.5 mEq/L

1. The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Use a walker when weakness occurs b. Avoid extreme environmental temperatures c. Increase daily intake of sodium in diet d. Take prescribed cortisone accurately

d. Take prescribed cortisone accurately

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse a. True urinary output of 50ml/hr b. Lower abdominal tenderness c. Blood urine output with clots d. Urine leaking around the meatus

d. Urine leaking around the meatus

A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? a. Reports subjective symptom's during hemodialysis b. Documents his oral intake during dialysis treatments c. Demonstrates self-care of the arteriovenous (AV) Shunt d. Verbalizes understanding of the reasoning for dialysis

d. Verbalizes understanding of the reasoning for dialysis

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Auscultate for the presence of bowel sounds. b. Monitor hemoglobin and hematocrit c. Encourage turning and deep breathing d. Administer IV antibiotics as prescribed

d. Administer IV antibiotics as prescribed

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? a. Encourage frequent mouth care b. Cleanse the tongue and mouth with glycerin swabs c. Obtain a soft diet for the client d. Administer a topical analgesic per PRN protocol.

d. Administer a topical analgesic per PRN protocol.

Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement? a. Palpate the abdomen b. Measure hourly urine output c. Ambulate client in hallway d. Auscultate bowels sounds.

d. Auscultate bowels sounds.

The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? a. Uses only lactose-free dairy products. b. Enjoys fat free yogurt as an occasional snack food c. No longer includes grains in his daily diet d. Carefully cleans and peels all fresh fruit and vegetables

d. Carefully cleans and peels all fresh fruit and vegetables

An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? a. Determine clients last dose of corticosteroids b. Determine neurological baseline prior to the fall c. Administer a PRN IV antiemetic as prescribed d. Complete head to toe neurological assessment.

d. Complete head to toe neurological assessment.

An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? a. Encourage the family to offer to feed the client when she does not eat her entire meal. b. Suggest that the family bring foods from home that the client enjoys c. Explain that weight loss will be reversed after the acute phase of the stroke has ended. d. Demonstrate the use of visual scanning during meals to the client and family.

d. Demonstrate the use of visual scanning during meals to the client and family.

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? a. Prepare for transcutaneous pacing b. Deliver another defibrillator shock c. Administer IV Epinephrine per ACLS protocol d. Give IV dose of adenosine rapidly over 1-2 seconds.

d. Give IV dose of adenosine rapidly over 1-2 seconds.

An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? a. Assist the lien tot a high Fowler's position in bed b. Observe the client for the presence of a barrel chest c. Prepare to transfer the client to a critical care unit d. Instruct the client to pursed lip breathing techniques

d. Instruct the client to pursed lip breathing techniques

A

which statement about a patient with a tube feeding indicates best practice for patient safety & quality care? A) if the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a 50 mL piston syringe B) when administering medications, use cold water to dissolve the drug before administering it C) use cranberry juice to flush the tube if it is clogged D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the drug is given