HESI V1

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first? a. Provide a supportive, structured environment for meals. b. Assess weight, vital signs, potassium and other electrolytes. c. Discuss alternative strategies for binging and purging. d. Monitor the client after meals for possible vomiting.

ANS: B Physiologic stability must be established first (B), and assessing the client's current weight, vital signs and electrolyte status provides baseline information. (A, C, and D) are interventions that should be implemented after assessing the client's current physiological state.

The nurse is caring for a client whose urine drug screen is positive for cocaine. What behavior is this client likely to exhibit during cocaine withdrawal? a. Intense cravings. b. Increased energy. c. Talkativeness. d. Euphoria

ANS: A During cocaine withdrawal, the nurse should expect the client to experience cravings (A) and a pattern of withdrawal symptoms similar to amphetamine use. (B, C, and D) are signs and symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal.

A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? a. Initiate normal saline IV at 50 ml/hr. b. Administer a loading dose of penicillin IM. c. Obtain a culture of any sputum or wound drainage. d. Administer the initial dose of folic acid PO.

ANS: A The most important intervention is the initiation of IV fluids (A) because hydration promotes hemodilution and RBC circulation. (B, C, and D) are also important interventions that should be implemented by the nurse, but after initiating administration of the IV fluids.

ng a home visit, the nurse should evaluate the adequacy of a client's treatment for COPD by assessing for which primary symptom? a. Dyspnea b. Tachycardia. c. Unilateral diminished breath sounds. d. Edema of the ankles.

ANS: A The most prominent finding in COPD is increasing dyspnea (A). (B) would not be a respiratory outcome, but might be a later manifestation. If breath sounds are diminished as a result of COPD, it would usually be a bilateral, not unilateral (C) problem. (D) is a sign of right-side heart failure.

The charge nurse should intervene when what behavior is observed? a. Two staff members are overheard talking about a cure for AIDS outside a client's room. b. A hospital transporter is reading a client's history and physical while waiting for an elevator. c. A UAP tells a client, "It's hard to quit drinking but Alcoholic Anonymous helped me." d. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.

ANS: B Only healthcare providers who need to see a client's record to provide care for that client should have access to such records. The transporter does not have need of the client's record to provide the care for which he/she has been charged (B). General medical discussions are always allowed (A). Staff may choose to share appropriate personal information with the client (C). It is not the charge nurse's role to correct visitor behavior (D).

In evaluating teaching of a client about wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure? a. "I must record any symptoms occurring with my activity." b. "I am not looking forward to staying in bed for 24 hours." c. "I really am dreading the frequent blood drawing." d. "I know that I shouldn't get close to my microwave oven."

ANS: A A Holter monitor is a continuous recording device designed to detect dysrhythmias during ADLs. The client should keep a diary of activity, noting the time of any symptoms, experiences, or unusual activities performed (A). The client should perform normal activities (B). Blood samples are not routinely drawn (C). A Holter monitor will not be affected by a microwave oven (D).

A male client asks the nurse how long his hospital stay will be following his scheduled surgery. Which resource provides the best guide for the nurse in responding to the client? a. Critical pathway for the scheduled surgery. b. Diagnosis-related group (DRG) for the surgery. c. The client's preferred provider arrangement. d. Standards of clinical nursing practice.

ANS: A A critical pathway (A) is an interdisciplinary plan that includes expected outcomes across a timeline, and is a useful resource in responding to the client. (B and C) are resources related to reimbursement. (D) describes general responsibilities for which the nurse is accountable.

A 10-year-old child with meningitis is suspected of having diabetes insipidus. In evaluating the child's laboratory values, which finding is indicative of diabetes insipidus? a. Decreased urine specific gravity. b. Elevated urine glucose. c. Decreased serum potassium. d. Increased serum sodium.

ANS: A A decreased urine specific gravity (A) often occurs with diabetes insipidus because the antidiuretic hormone is not present to promote reabsorption from the kidneys. The kidneys fail to concentrate urine, resulting in excretion of large amounts of dilute urine. (B) is not found with diabetes insipidus, as it is with diabetes mellitus. (C and D) can occur with a variety of conditions, including diabetes insipidus, but they are not particularly indicative of diabetes insipidus, as is (A).

Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse to provide for this 3-year-old child? a. Set of cloth hand puppets. b. Barbie doll and clothes. c. Duck that squeaks. d. Hand-held video game.

ANS: A A spica cast is used to immobilize the hip and knee. A set of cloth hand puppets (A) provides an activity that promotes creativity while maintaining safety. (B) has small parts that could be inserted into the cast, which may result in cellulitis. (C) is too noisy and appropriate for a younger child, whereas (D) would entertain a school-aged child.

It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation? a. A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate. b. A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells. c. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside. d. An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.

ANS: A Access of an implanted port is a skill that requires experience and expertise, so it is important for the RN to supervise a graduate nurse performing this task (A). An experienced nurse should be able to start a blood transfusion (B) regardless of the setting, and should not require direct supervision. The practical nurse should be able to assist with a procedure such as a lumbar puncture (C) without direct supervision, and the UAP (D) can perform this skill without direct supervision.

Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? a. An adult who had a colon resection yesterday and has an IV. b. An older adult who has a fever of unknown origin. c. A woman who had an acute brain attack (stroke, CVA) 6 hours ago. d. A teenager with a femoral fracture who is in traction.

ANS: A An OB nurse is usually experienced in caring for abdominal surgical wounds (cesarean sections) and IV infusions, so the adult who had a colon resection would be the best choice (A). The nurse should not knowingly be exposed to infectious organisms (B) since OB is considered a "clean area," and the nurse will be returning to work on the OB unit. Ordinarily, OB nurses are not experienced in assessing and managing care for stroke victims (C) or clients who are in traction (D).

An outcome for treatment of peripheral vascular disease is, "the client will have decreased venous congestion." What client behavior would indicate to the nurse that this outcome has been met? a. Avoids prolonged sitting or standing. b. Avoids trauma and irritation to skin. c. Wears protective shoes. d. Quits smoking.

ANS: A Client behaviors indicating that the expected outcome of, "decreased venous congestion" has been met would include elevating the legs, increasing walking time, and an observable decrease in edema of the lower extremities (A). (B and C) would be appropriate for outcomes for, "Attains or maintains tissue integrity." (D) would be an appropriate outcome for, "Demonstrates an increase in arterial blood supply to extremities."

The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool. b. Splint affected joints during activity. c. Perform passive range of motion exercises twice daily. d. Begin a training program lifting weights and running.

ANS: A Exercising in a swimming pool (A) allows freedom of movement with minimum gravitational pull and thereby less discomfort. Physical therapy for clients with JRA is directed toward specific joints and focuses on strengthening muscles, mobilizing restricted joints, and preventing or correcting deformities. Splinting and positioning of joints helps to minimize pain, prevents or reduces flexion deformities, and is recommended during periods of rest (B). To strengthen and mobilize towards maximizing independence, the adolescent should engage in active (not passive) range of motion exercises (C). (D) may be a more painful weight-bearing activity and the adolescent's previous level of activities should be considered.

Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions? a. Assessing pedal pulses frequently and monitoring the nasogastric drainage. b. Maintaining strict bedrest for 72 hours and assessing radial pulses. c. Monitoring an infusion of IV heparin and checking the PTT level daily. d. Assessing the right flank dressing and monitoring the suprapubic Foley catheter.

ANS: A Following surgical repair of an abdominal aortic aneurysm, an N/G tube is needed to decompress the stomach, and the pedal and posterior tibial pulses need to be assessed frequently to ensure that the graft is patent (A). Clients are usually encouraged to be out of bed on the first postoperative day and radial pulses are in the unaffected upper extremities (B). (C) is contraindicated. An abdominal dressing would be in place rather than a right flank dressing, and the client would not have a suprapubic catheter (D).

The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel a. Remove the glass of water and speak to the UAP. b. Discuss the incident with the UAP at the end of the day. c. Write an incident report and notify the healthcare provider. d. Remind the client of the potential for electrolyte imbalance.

ANS: A It is important to immediately stop the potential harm to the client by removing the water and speaking to the UAP (A). (B and C) do not prevent a reoccurrence. The client may not be able to understand pathophysiologic rationale (D). It is the nurse's responsibility to safeguard the client and ensure that the unlicensed staff working with the nurse provide safe care.

Which assessment is most important for the nurse to complete to determine a client's tolerance for ambulation? a. Respiratory rate. b. Capillary refill. c. Pedal pulses. d. Skin turgor.

ANS: A Mobilization and ambulation increase the utilization of oxygen, so the nurse should assess the client's respiratory rate (A), which is useful information about the client's tolerance for activity. (B, C, and D) are less likely to provide data related to exercise tolerance.

A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first? a. Check the blood glucose level. b. Draw blood for a Hemoglobin A1C. c. Assess urine for ketone levels. d. Provide the client with a protein snack.

ANS: A Nausea, tremors, and lethargy are common discomforts associated with the first trimester of pregnancy. However, this client has Type 1 diabetes, so she should be assessed for hypoglycemia (A) because insulin needs often decrease in the first trimester. (B) should be assessed to determine the control of the client's diabetes for the last 3 to 4 months and the urine assessed for ketones (C), but the most immediate need is to assess for hypoglycemia. If the client is hypoglycemic, a complex carbohydrate such as graham crackers and peanut butter should be provided, rather than a protein snack (D).

A 25-year-old male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. What is the most important information for the nurse to include in the teaching plan? a. Avoid penile contact with the rectal area. b. Epididymitis is a pre-cancerous condition. c. Obtain an annual prostate digital exam. d. Surgical intervention is often indicated.

ANS: A Since the most common source of E. coli in the body is from the rectal area, males need to remember when having sexual contact to avoid contacting the rectal area (A) of their partner. (B) is incorrect. It is not generally associated with prostate problems (C). The condition is more prevalent in older men who have recently had prostate surgery. (D) is rarely necessary.

A client has 2nd degree electrical burns on both upper extremities. The nurse is preparing to administer the first application of the topical antimicrobial agent mafenide acetate (Sulfamylon) to the burned area. Which intervention should the nurse implement first? a. Premedicate the client prior to applying the medication. b. Use sterile gloves when applying this medication. c. Cleanse the burned area with sterile normal saline. d. Assess the client's most recent arterial blood gas test results.

ANS: A Sulfamylon penetrates thick eschar and is excellent for treating electrical burns, but causes pain that lasts about 30 to 40 minutes after being applied, so the nurse should premedicate the client for pain (A). (B and C) should be implemented after premedicating the client. ABGs (D) should be evaluated after treatment because this medication can cause metabolic acidosis, but it will do no good to assess the client's ABGs prior to the first application.

The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first? a. The mother who took her children from school because aliens were after them. b. The young man who has a history of substance abuse and has no telephone. c. The newly diagnosed client who needs to be evaluated for medication compliance. d. The young woman who believes she is to blame for her recent miscarriage.

ANS: A The client who is exhibiting paranoid behavior (A) has a high risk of harming herself or her children, so the nurse should plan to visit this client first. (B) is not in immediate danger. (C) is not a high priority. Although (D) may be experiencing depression, she does not have the priority of a client with paranoid ideation who is having hallucinations about her children's safety.

A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? a. Reschedule administration of the antibiotic until after he completes his prayers. b. Instruct the client that the antibiotics must be given on time to be effective. c. Notify the healthcare provider that the client has refused the scheduled antibiotic. d. Ask the pharmacist to supply an oral form of the antibiotic for the client.

ANS: A The nurse must respect the client's refusal of treatment and also develop a plan to ensure that the client receives the needed medication. Therefore, the nurse should reschedule (A) the medication for times that are acceptable to the client. The client's refusal is based on cultural values, rather than lack of knowledge, so (B) will not resolve the problem. While the nurse may need to notify the healthcare provider of the change in the dosage schedule (C), this action will not resolve the problem as effectively as (A). The nurse cannot prescribe a change in medication route (D).

Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bowel sounds and firm, distended abdomen. Which prescription for the client should the nurse question? a. Continous tube feeding at 65 ml/hr via gastrostomy. b. Total parenteral nutrition to be infused at 125 ml/hour. c. Nasogastric tube connected to low intermittent suction. d. Metoclopramide (Reglan) intermittent piggyback.

ANS: A The nurse should question the administration of a tube feeding into the GI tract (A), which may result in vomiting and aspiration, because the client is exhibiting signs of decreased peristalsis and possible bowel obstruction. (B) provides a means of safely providing nutrition while GI tract function is inhibited. (C) benefits the client by reducing any excess gastric contents. (D) helps stimulate peristalsis.

A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first? a. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. b. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours. c. Pantoprazole (Protonix) 40 mg PO daily d. Enoxaparin (Lovenox) 40 mg subq q24 hours.

ANS: A Therapeutic serum levels of antibiotics should be maintained to treat infections such as urosepsis. The Zosyn should be administered first (A) because Vancomycin must be infused over at least 90 minutes and if administered first would delay the administration of the Zosyn by one and one-half hours (B). No ill effects will result from a short delay in the administration of the Protonix (C) or Lovenox (D).

A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective? a. The client's extremities are paralyzed. b. The peripheral nerve stimulator causes twitching. c. The client clinches fist upon command. d. The client's Glasgow Coma Scale score is 14.

ANS: A This medication causes paralysis (A) following intravenous injection. Peak effects persist for 35 to 60 minutes. (B and C) would not be possible if the medication is effective. The Glasgow coma scale is used to evaluate the neurological status of the client and does not evaluate the effectiveness (D) of this medication.

The nurse is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention? a. Weigh the child daily. b. Observe the lower extremities for pitting edema. c. Measure the child's abdominal girth weekly. d. Weigh the child's wet diapers.

ANS: A Weighing the child daily (A), or more often, is the best intervention for detecting fluid retention. (B) should be implemented, but provides a less accurate measure of fluid retention than (A). (C) is not a good evaluator of fluid retention, but could be used to determine an obstruction. (D) is an appropriate and necessary intervention for a child with nephrotic syndrome, but it is used to obtain I&O, and is not an accurate determination of weight gain, which reflects fluid retention.

A client with which problem requires the most immediate intervention by the nurse? a. Finger paresthesias related to carpal tunnel syndrome. b. Increasing sharp pain related to compartment syndrome. c. Increasing burning pain related to a Morton's neuroma. d. Increasing sharp pain related to plantar fasciitis.

ANS: B (B) represents the most acute problem, since increasing pain associated with compartment syndrome may indicate that additional swelling is compromising circulation and nerve function. (A, C, and D) are less acute problems, since no compromise of circulation is involved.

The nurse learns that a newly admitted adult client has a six month history of recurring somatic pain. During the admission interview, it is most important for the nurse to question the client about what problem ? a. Episodes of tremors. b. Feelings of depression. c. Periods of restlessness. d. Nausea and vomiting.

ANS: B A large percentage of clients who experience chronic pain become clinically depressed, so it is essential that the nurse question the client about feelings of depression (B). Tremors (A) are not commonly associated with chronic pain. Clients with chronic pain are more likely to experience fatigue than (C). (D) may be experienced if the client is receiving certain analgesics, but gastric distress is not as typically associated with chronic pain as is depression.

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding? a. 4+ pitting edema of both lower extremities. b. A Braden risk assessment scale rating score of ten. c. Warm, dry skin with a fever of 100° F. d. Hypoactive bowel sounds with infrequent bowel movements.

ANS: B A score of ten (B) on the Braden risk assessment scale indicates that the client should be turned frequently. This scale is a reliable tool used to measure the client's risk for the development of pressure sores. Scores range from 6 to 23, with the lowest score indicating the highest risk for pressure sore development. (A) indicates that the client's feet may need to be elevated, which can be accomplished regardless of the turning schedule. (C and D) indicate that turning will be beneficial, but these are less specific than (B) with regard to the need for frequent turning.

A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective? a. Reports reduced nasal discharge. b. Denies having coughing spells. c. Able to sleep through the night. d. Expectorating bronchial secretions.

ANS: B Antitussives suppress the cough reflex by acting on the cough control center in the medulla (B). Antihistamines are prescribed for watery nasal discharge (A) secondary to allergic rhinitis. A side effect of antihistamines is drowsiness (C), not antitussives. Expectorants (D) are prescribed to help remove secretions from the lungs.

A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse? a. The nurse is guilty of negligence and will be sued. b. The client would not be able to prove malpractice in court. c. The nurse is protected by the Good Samaritan Act. d. The healthcare provider should have given the morphine sulfate dose.

ANS: B Because the client would not be able to show that the nurse's actions resulted in injury, she would not be able to prove that the nurse was guilty of malpractice (B). For this reason, the nurse is not guilty of negligence (A). The Good Samaritan Act (C) does not protect nurses who have established a nurse-client relationship as a function of their job duties. The administration of the morphine sulfate falls within the scope of registered nurse practice in all states, so (D) is not necessary.

A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client? a. Glasgow coma scale. b. Pulses, paresthesia, paralysis distal to the right knee. c. Pulses, paresthesia, paralysis proximal to the right knee. d. Optic nerve using an ophthalmoscope.

ANS: B Clients with edema require a neurovascular assessment distal to the problem area (B), not proximal (C). (A and D) may reveal abnormalities, but are not a priority for the presenting complaint.

An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report? a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due to dehydration. b. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage. c. Expect to find an increase in today's APTT as compared to last quarter's due to bleeding. d. Determine if there is a decrease in serum potassium due to renal compromise.

ANS: B Frequent and/or large doses of acetaminophen can cause an increase in liver enzymes, indicating possible liver damage (B). If the client reported unusual bleeding, or an increase in aspirin usage, it would be important for the nurse to assess for increased bleeding and monitor (A and/or C). (D) is not affected by increases in acetaminophen doses.

The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? a. Repair should be done by one month to prevent bladder infections. b. Repairs typically should be done before the child is potty-trained. c. Delaying the repair until school age reduces castration fears. d. To form a proper urethra repair, it should be done after sexual maturity.

ANS: B Hypospadias repair is often done between 6 and 18 months, depending on the repair needed and whether it is done in one or two stages. Psychologically, it helps the child and parents if the repair is done prior to the child having genital awareness and is standing to urinate (B). (A) may occur, but infants tolerate anesthesia better after 6 months of age. (C and D) can have psychological effects related to issues of body-image and self-concept.

A client is hemiplegic following a cerebrovascular accident. To prevent this client from experiencing a painful shoulder, what intervention should the nurse include in the plan of care? a. Exercise the affected shoulder by using it when assisting the client out of bed. b. Position the affected arm on pillows while the client is seated in a chair. c. Keep the client's affected arm elevated above the level of the heart. d. Avoid range of motion exercises on the affected shoulder until pain in the shoulder has passed.

ANS: B If the arm is paralyzed, subluxation at the shoulder can occur from overstretching of the joint capsule and musculature by the force of gravity. This can be prevented by positioning and supporting the affected arm (B). The nurse should never lift the client by the flaccid shoulder or pull on the affected arm or shoulder (A). (C) would be ineffective against pain. To prevent contractures, passive range of motion exercises should be performed supporting the arm proximal to the joint being moved (D).

An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take? a. Notify the unit manager that an emergency court order is needed to allow the surgery. b. Continue to prepare the client for the surgery without a signed informed consent. c. Ask the woman's friend to sign the informed consent since the client is unresponsive. d. Maintain continuous monitoring of the client until a family member can be located.

ANS: B In emergency situations, if it is impossible to obtain consent from the client or an authorized person, the procedure required to save the client's life may be undertaken without liability for failure to obtain consent (B). In such cases, the law assumes that the client would wish to be treated, so (A) is not needed. A friend (C) cannot sign the informed consent. (D) constitutes failure to act, in this case by withholding a life-saving treatment until a family member can be located.

A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? a. "Milk does contain tryptophan, which helps many people fall asleep." b. "Drinking milk before bedtime can increase your symptoms at night." c. "A warm drink, such as hot tea or cocoa should be substituted for the milk." d. "Taking an antispasmodic medication with the milk will reduce the symptoms."

ANS: B Milk products increase gastric acid production and should be avoided, especially at night (B). The benefit of the tryptophan is outweighed by the harmful effect of milk when drinking it before bedtime, for the client with GERD (A). (C), along with coffee and peppermint, predispose the client to reflux. (D) is not useful in the management of GERD.

The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology, secondary to the medication's effects, places the client at risk for injury? a. Bleeding complications. b. Adverse CNS effects. c. Electrolyte imbalance. d. Immune system suppression.

ANS: B Nubain is a strong analgesic with adverse CNS effects that include sedation, confusion, and respiratory depression (B). Nubain does not result in (A, C, or D).

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? a. Administer oxygen via face mask. c. Notify the operating room team. b. Place the client in Trendelenburg. c. Administer a fluid bolus of 500 ml.

ANS: B Placing the client in a Trendelenburg position (C) helps to relieve the pressure of the presenting part on the cord. The nurse should try to remove pressure of the presenting part on the cord, and this is accomplished by vaginal exam and holding up the presenting part as much as possible. (A and B) are important actions for the nurse to perform, but do not have the priority of placing the client in Trendelenburg position. (D) is not indicated in this situation.

A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report? a. Refuses to eat her favorite meals at home. b. Drinks more soft drinks than previously. c. Voids only one or two times per day. d. Gained 10 pounds within one month.

ANS: B Polydipsia (B), polyuria, and polyphagia are key signs of diabetes in children and adults. (A and C) are not associated with diabetes in children. (D) is not usually characteristic of diabetes in children, but is associated with diabetes in adults.

The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals? a. Prevents indigestion associated with ingestion of spicy foods. b. Binds with phosphorus in foods and prevents absorption. c. Promotes stomach emptying and prevents gastric reflux. d. Buffers hydrochloric acid and prevents gastric erosion.

ANS: B RenaGel is an intestinal phosphate binder and should be taken with meals to prevent contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and D) are not the therapeutic actions of RenaGel.

When is the best time for the nurse to assess a client for residual urine? a. When the client's bladder is distended. b. Immediately after the client voids. c. Just prior to the client voiding. d. After draining the urinary catheter bag.

ANS: B Residual urine is the urine left in the bladder after a client voids, so assessment for residual urine should be done immediately after a client voids (B). (A, C, and D) would not be the appropriate time to measure residual urine.

While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement? a. Permit privacy for the mother and infant to bond. b. Assist the mother to elicit a rooting reflex in the infant. c. Place a small amount of glucose water on the breast. d. Evaluate the infant's sucking reflex then give the infant to the mother.

ANS: B Stimulation of the rooting reflex (B) is effective in helping the infant grasp the nipple for breastfeeding. (A) may frustrate a first-time new mother. (C) does not assist the infant to open its mouth to grasp the nipple. (D) is not necessary prior to giving the infant to the mother--it can be evaluated while helping the infant to grasp the nipple.

The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid? a. Toasted white bread with butter. b. Whole grain cereal and milk. c. Hard-boiled egg and juice. d. Vanilla milkshake with protein supplement.

ANS: B The best food sources of dietary folate include whole grain breads and cereals (B). Other foods high in folate are fresh green leafy vegetables, liver, and peanuts. (A, C, and D) are not the best sources of folic acid, although (C and D) are good sources of protein and vitamin D.

The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? a. "It will help you function better in the community." b. "The medication will help you think more clearly." c. "You will be able to cope with your symptoms." d. "It will improve your grooming and hygiene."

ANS: B The best response is that the medication will help the client to think more clearly (B). Ultimately, because of improved thinking, the antipsychotic medication is likely to also assist the client with (A, C, and D).

An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one finger-breadth above the umbilicus. What action should the charge nurse implement first? a. Notify the healthcare provider of the assessment findings. b. Determine if the client received anesthesia during delivery. c. Assign a practical nurse (PN) to reassess the client's vital signs. d. Obtain a STAT hemoglobin and hematocrit.

ANS: B The charge nurse should review the delivery record to determine if the client received epidural anesthesia because a spinal headache is a complication that occurs in approximately 2% of those who receive epidural anesthesia (B). The healthcare provider should be notified (A) after additional information is obtained regarding labor anesthesia. There is no reason to suspect that the UAP obtained inaccurate vital signs (C). (D) might be obtained to assess for excessive bleeding, but the assessment findings do not indicate the possibility of hemorrhage.

An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented? a. Obtain a urine specimen for culture and sensitivity. b. Encourage the client to schedule a digital rectal exam. c. Advise the client to maintain a voiding diary for one week. d. Instruct the client in effective techniques to cleanse the glans penis.

ANS: B The client is exhibiting classic signs of an enlarged prostate gland, which restricts urine flow, and needs further evaluation for diagnosis. This can be done by digital rectal exam (B), so the nurse should encourage the client to schedule this evaluation. (A, C, and D) are not warranted based on the client's symptoms.

A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time? a. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant. b. Help the client place a call to the HMO to seek information about limitations of coverage. c. Encourage the client to call a lawyer so that a lawsuit can be filed against the HMO if necessary. d. Have the social worker call the state board of insurance to register a complaint against the HMO.

ANS: B The client needs to contact her HMO first (B) to see if a transplant is a covered treatment option. If the transplant is not covered by the HMO, the client may be able to seek recourse as explained in the Patient's Bill of Rights published by the American Hospital Association. (A, C, and D) describe actions that are premature at this time.

The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearance" for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis? a. Pain when coughing. b. Diminished cough effort. c. Thick dry secretions. d. Excessive inflammation.

ANS: B The client with myasthenia gravis experiences fatigue and muscle weakness, which is likely to result in a diminished cough effort (B). (A, C, and D) are not common in clients with myasthenia gravis.

A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority? a. Apply a hypothermia unit to stabilize core temperature. b. Increase the client's IV fluid rate to 200 ml/hr. c. Call the hospital chaplain to counsel the family. d. Draw blood cultures x 3 to detect infection.

ANS: B The client's hemodynamic pressures indicate severe volume depletion secondary to heat exhaustion or heat stroke, so the client's IV fluids should be increased to assist in correcting the volume deficit (B). (A, C, and D) are not useful in correcting the client's hypovolemic state, and may not be necessary in treating the client's condition.

A 36-year-old client is admitted to the ICU following a six-hour surgery to repair a fractured pelvis, and the estimated intraoperative blood loss (EBL) was 3,000 ml. Current client data include: BP 85/70, heart rate 140 beats/minute, urine output 10 ml/hr, PAWP 2, RAP -3, Hct 20%, Hgb 7 g/dl. What action should the nurse take at this time? a. Administer propranolol (Inderal) to decrease the heart rate. b. Infuse blood and IV fluids to correct the hypovolemia. c. Start a dopamine (Intropin) infusion to raise the BP. d. Draw serum blood cultures to check for infection.

ANS: B The client's hemodynamic readings indicate severe circulatory blood loss, and rapid replacement of RBCs and fluids is needed (B) to correct the hypovolemia. Vasopressors (A and C) are not effective in improving the client's hemodynamic status until volume is restored. Based on the data presented, (D) is not indicated at this time.

The nurse observes that a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement? a. Discontinue the IV and apply pressure at the site. b. Decrease the saline to a keep-open rate. c. Increase the rate of the current IV solution. d. Change the IV fluid to 0.45% normal saline at the same rate.

ANS: B The nurse should decrease the rate of the IV solution to a keep-open rate to avoid further fluid volume overload (B) while awaiting a change in prescription from the healthcare provider. The client has received a large amount of fluid in a short period of time and is exhibiting signs of fluid volume excess. An IV diuretic or other emergency medication may be prescribed, so the IV should not be removed (A). (C) will worsen the fluid volume excess already exhibited by the client. Changing the IV solution (D) to a hypotonic solution is likely to worsen the fluid volume excess.

The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm3. What intervention should the nurse implement? a. Increase Client A's oxygen to 4 liters per minute via nasal cannula. b. Determine if Client B has two units of packed cells available in the blood bank. c. Ask the dietician to add a banana to Client C's breakfast tray. d. Inform Client D that surgery is likely to be delayed until the infection is treated.

ANS: B The nurse should determine the availability of packed red blood cells for Client B (B) because the low hemoglobin during the postoperative period indicates the probable need for a blood transfusion. (A) would eliminate Client A's hypoxic drive that creates the urge to breathe, resulting in a respiratory arrest. Client C's potassium is within normal limits, and (C) will only help to maintain this level. Client D's elevated WBC is expected during the acute infectious process of an appendicitis attack and would not delay the surgery (D).

The nurse enters the room of a client with a history of seizure activity and observes that the unlicensed assistive personnel (UAP) is securing several pillows against the side rails to protect the client. What action should the nurse implement? a. Ensure that the UAP has placed the pillows effectively to protect the client. b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. c. Assume responsibility for placing the pillows while the UAP completes another task. d. Ask the UAP to use some of the pillows to prop the client in a side-lying position.

ANS: B The nurse should instruct the UAP to pad the side rails with soft blankets (B) because the use of pillows (A) could result in suffocation. The nurse can delegate padding the side rails to the UAP (C). A side-lying position (D) may help prevent aspiration during a seizure, but turning the client is not the priority when implementing seizure precautions.

While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take? a. Call 911 immediately then begin cardiopulmonary resuscitation. b. The Heimlich maneuver using chest thrusts. c. The Heimlich maneuver using sub-diaphragmatic thrusts. d. Cardiopulmonary resuscitation with uterine tilt.

ANS: B When foreign body airway obstruction is suspected in a gravid woman, the nurse should modify the Heimlich maneuver by applying chest thrusts (B). If the client is in cardiac or respiratory arrest then the nurse should have someone call 911 and begin CPR (A) with the appropriate modification for pregnancy (D). Using (C) is not recommended during pregnancy due to positional changes of internal organs such as the liver.

A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? a. Exhale forcefully into the tubing for 3 to 5 seconds. b. Inspire deeply and slowly over 3 to 5 seconds. c. Breathe into the spirometer using normal breath volumes. d. Perform IS breathing exercises every 6 hours.

ANS: B When using an incentive spirometer, the client should exhale fully, then place the mouthpiece in the mouth, and breathe in deeply and slowly over 3 to 5 seconds (B) to fully expand the lungs by using inspiratory muscles. (A) forces air out of the lungs, rather than increasing the inspiratory reserve volume, which hyper-inflates the alveoli to prevent atelectasis in the postoperative period. IS exercises should be done every two hours (D) while the client is awake during postoperative convalescence. (C) is used to measure tidal volume.

A client who has end-stage renal disease (ESRD) continues to be despondent after receiving the biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) for 3 weeks. Which parameters should the nurse assess when evaluating the effectiveness of this BRM? a. WBCs, neutrophil and T4 count. b. RBCs, hemoglobin, and hematocrit. c. Blood pressure, heart rate, and temperature. d. Serum potassium, calcium, and phosphorus.

ANS: B With ESRD, the renal parenchyma does not produce erythropoietin, resulting in chronic anemia. Epogen is prescribed to attain and maintain a hematocrit of 30% to 36% (B), which should increase within 2 weeks of treatment with these drugs. The client's despondent affect indicates the need for an assessment for depression. (A) lists indices to assess immunological status. (C) is a clinical parameter that may respond to the therapeutic action of Epogen, but the lab values provide more accurate clinical markers after 2+ weeks of treatment. (D) lists electrolytes that should be monitored in ESRD and could influence the client's affect, but do not respond to this BRM.

The nurse is performing an admission physical assessment of a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider? a. Heel stick glucose of 65 mg/dl. b. Head circumference of 35 cm (14 inches). c. Widened, tense, bulging fontanel. d. High-pitched shrill cry.

ANS: C (C) is indicative of increased intracranial pressure (ICP) that is expanding suture lines and fontanel tension. Normal capillary glucose for a neonate ranges between 40- 80 mg/dl (A). (B) is at the upper limits of an average gestational age neonate, and the frontal occipital circumference should be compared with other measurements for the SGA neonate when reporting the finding. (D) is consistent with increased ICP and may also be seen in congenital or chromosomal defects that alter vocal cord structure, and should be reported, but (C) is the most critical finding to report.

In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should recognize that which intervention is essential? a. Keep the arm and shoulder of the affected side immobile at all times. b. Ensure that there is no fluctuation in the water-seal chamber. c. Encourage the client to breathe deeply and cough at frequent intervals. d. Maintain the Pleuravac® slightly above the chest level.

ANS: C (C) will help raise intrapleural pressure which allows emptying of any accumulation in the pleural space and helps the lung reexpand. Range of motion exercises (A) should be done on the affected side to help prevent ankylosis of the shoulder and assist in lessening pain and discomfort. There should be fluctuation of the water level (B) because this shows there is communication between the pleural cavity and drainage bottle. The Pleuravac® should be kept below chest level (D) to prevent backflow of fluid into the pleural space.

The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant receive? a. 9 mg. b. 18 mg. c. 27 mg. d. 36 mg.

ANS: C 4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25 ml of D5W, is not relevant to the calculation requested.

A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? a. Tell him he can have a day pass if he calms down. b. Put the client's behavior on extinction. c. Decrease the volume on the television set. d. Instruct the client to sit down and be quiet.

ANS: C Any stimulus (sound) can be perceived as a threat and the client cannot deal with excess stimuli when agitated, so decreasing the volume on the TV may help to reduce the aggression by reducing external stimuli. (A) is manipulative and cannot be implemented. Extinction (ignoring the behavior) (B) is not indicated since the client is a danger to self or others, and safety is a priority. (D) could incite more anger and the client should be removed from the area to help ensure safety.

Prior to obtaining an axillary temperature, the nurse should perform which action? a. Check the last oral temperature reading. b. Ask the client when he last ate or drank. c. Place a protective sheath over the thermometer. d. Position the client's arm at heart level.

ANS: C Before the thermometer is placed under the arm, a sheath should be used to cover and protect the thermometer (C). (A) is of little use when preparing to assess an axillary temperature, and (B) should be done prior to an oral temperature. (D) is necessary when obtaining a blood pressure measurement, but not a temperature reading.

The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client's medication administration record (MAR). Which action should the nurse take to prevent a medication error from occurring? a. Compare the medication label with the medication administration record (MAR). b. Check the client's identification bracelet prior to administering the medication. c. Compare the medication administration record (MAR) to the prescription. d. Verify the room number on the medication administration record (MAR).

ANS: C Comparing the MAR to the original prescription in the chart for accuracy ensures that the prescription was entered correctly (C). ( A, B, and D) are all safety measures the nurse should take when administering medications, but these interventions do not ensure the medication was transcribed accurately.

A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has "little reason to live." She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement? a. Encourage the client to remove the gun from her possession. b. Notify the client's healthcare provider of the availability of the weapon. c. Contact a person of the client's choosing to remove the weapon from the home. d. Call the local police department and have the weapon removed from the home.

ANS: C Contacting someone (C) of the client's choosing helps to maintain her confidentiality since she chooses the person to remove the weapon, but also ensures safety in that the gun is removed by another person. (A) is not as safe an intervention as having someone else remove the weapon. The healthcare provider must be notified of any suicidal ideation regardless of the severity of the ideation (B), but safety has a higher priority than communication with the healthcare provider. (D) violates the client's confidentiality and, though safety is a higher priority than confidentiality, (C) provides both.

A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response? a. "You are lucky to be alive. Be grateful no one was killed." b. "I understand your car was not seriously damaged." c. "You are upset that this incident has brought you here." d. "Have you ever been in the emergency department before?"

ANS: C Even if the client has not been seriously hurt, she has been inconvenienced by the incident and it is appropriate for her to be angry. The nurse can clarify the client's feelings (C). (A) is a barrier to communication and shames the client for feeling angry. (B) changes the subject and does not address the client's anger--even minor car repairs can cause major inconveniences. (D) does not address the client's feelings and may bring up unpleasant memories the client does not wish to share at this time.

The nurse is conducting assessments at the beginning of the shift. Which client is most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago? a. A young female with increased urinary output following administration of IV furosemide (Lasix). b. A middle-aged male receiving prazosin hydrochloride (Minipress). c. An elderly male who received two units of packed red blood cells (RBCs). d. An adolescent who is receiving azathioprine (Imuran) following a cardiac transplant.

ANS: C Following an infusion of 2 units of RBCs (C), fluid volume in the vasculature increases, which increases cardiac preload, thus increasing cardiac output, which is reflected in an increased blood pressure. Administering (A), a loop diuretic, or (B), an alpha adrenergic blocking agent, causes a lowering of the blood pressure. (D), an immunosuppressant, has no direct effect on the blood pressure.

A client diagnosed with Type 1 diabetes is NPO for a diagnostic test. The nurse is preparing to administer 24 units of 70/30 insulin. Which intervention should the nurse implement first? a. Administer the insulin subcutaneously in the client's abdomen. b. Administer the insulin when the client returns from the test. c. Contact the healthcare provider to adjust the insulin dose. d. Call the department and request that this client's test be done first.

ANS: C Glucose levels may rise as a result of hepatic glucose production even if the client is NPO, so the insulin dosage needs to be changed (C) by either omitting the morning dose or administering regular insulin. (A) may cause the client to experience hypoglycemia. (B) may result in hyperglycemia. (D) does not fully address the problem, so adjusting the insulin dose is the better solution.

An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client? a. Delirium b. Presbyopia c. Presbycusis d. Cerebral dysfunction.

ANS: C Presbycusis (C) is the term for changes in auditory acuity related to age. He is probably losing his hearing. (A) is exhibited by an acute confusion and no data have been provided to suggest that this client is confused. (B) is a visual decline in the ability to focus on fine detail which occurs after the age of 40. (D) is a decline in mental functioning as seen in Alzheimer's disease.

The community health nurse must provide a primary prevention program in the community. Which type of program addresses this need? a. Provide a nurse-practitioner to prescribe medications for clients with heart disease. b. Arrange cardiac-prudent diets to be delivered to individuals using Meals on Wheels. c. Incorporate an exercise program at a local Hispanic community center. d. Conduct a weekly blood pressure screening at the Hispanic senior citizen center.

ANS: C Primary prevention is providing health teaching to prevent disease, so an exercise class (C) may help prevent heart disease, which is prevalent in the Hispanic population. (A) is tertiary prevention. (B and D) are examples of secondary prevention.

What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum? a. Soft, spongy fundus. b. Saturating two perineal pads per hour. c. Pulse rate of 56 BPM. d. Unilateral lower leg pain.

ANS: C Puerperal bradycardia (C) is a normal finding in the early postpartum period due to the vast vasomotor changes occurring in the maternal vascular bed. (A) would not be likely nor normal for a primiparous client. (B) is excessive lochial flow and is a sign of hemorrhage (one saturated pad/hour is normal). (D) may indicate thrombus development.

After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next? a. Open the isolette door to assess the infant's vital signs. b. Place erythromycin ophthalmic ointment in both eyes. c. Remove the wet blankets and linens from the isolette. d. Administer the vitamin K (AquaMEPHYTON) injection.

ANS: C Removing wet blankets and linens from the isolette (C) would prevent further heat loss from radiation. To assess the infant, the isolette door should remain closed (A) to prevent heat loss. (B and D) are given within 2 hours of birth.

Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement? a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath. b. Administer the aspirin with at least two ounces of water or juice. c. Notify the healthcare provider if the child complains of ringing in the ears. d. Advise the parents to question the child about seeing yellow halos around objects.

ANS: C Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and should be reported immediately. Though a tepid sponge bath may lower the child's temperature, the prescription for aspirin should not be held (A). Aspirin should be taken with at least eight ounces of water to completely wash the tablet into the stomach and to help prevent GI discomfort (B). Yellow halos are associated with Digoxin toxicity, not aspirin (D).

While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding? a. Palpate for the presence of femoral pulses bilaterally. b. Assess for the presence of a positive Homan's sign. c. Observe the appearance of the skin on the client's legs. d. Watch the client's posture and balance during ambulation.

ANS: C Signs of chronic arterial insufficiency include decreased hair growth in the legs and feet, absent or decreased pedal pulses, infection in the foot, poor wound healing, thickened nails, and a shiny appearance of the skin (C). Femoral pulses (A) should still be palpable in the diabetic with chronic arterial insufficiency. A positive Homan's sign is an indicator of deep vein thrombosis (B). (D) would probably not be affected significantly by chronic arterial insufficiency.

When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling "out of breath" but denies any other complaints. What action should the nurse take at this time? a. Administer a PRN prescription for diphenhydramine (Benadryl). b. Start the normal saline attached to the Y- tubing at the same rate. c. Decrease the intravenous flow rate of the PRBC transfusion. d. Ask the respiratory therapist to administer PRN albuterol (Ventolin.).

ANS: C The client is exhibiting symptoms of fluid volume overload because 200 ml of the 250 ml unit of packed red blood cells infused in 30 minutes, so the best action is to decrease the flow rate of the transfusion (C). (A) is not necessary since there are no signs of a transfusion reaction, either hemolytic or allergic. (B) will contribute to the fluid overload. Though shortness of breath may be temporarily abated with (D), the priority intervention at this time is to slow the rate of infusion to prevent the fluid volume overload from worsening.

In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should the nurse implement? a. Continue the magnesium sulfate infusion as prescribed. b. Decrease the magnesium sulfate infusion by one-half. c. Stop the magnesium sulfate infusion immediately. d. Administer calcium gluconate immediately.

ANS: C The client is exhibiting symptoms of magnesium sulfate toxicity--decreased reflexes (normal is +2), a low normal respiratory rate (normal is 12 to 20 breaths/min), a less than average urinary output (30 ml/hour is average), and a low magnesium sulfate level (normal is 4 to 8mg/dl). Based on these findings, the nurse should stop the infusion (C). (A) is contraindicated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D) (the antagonist for magnesium sulfate) would be indicated if the respiratory rate were less than 12 breaths/minute.

Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy? a. Client denies allergies to contrast media. b. Skin prep to insertion site completed. c. On-call sedation administered. d. Oxygen at 2 L/minute per nasal cannula.

ANS: C The client should receive preprocedure sedation before leaving the nursing unit (C). Bronchoscopy involves insertion of a scope into the trachea via the nose or mouth, so (A or B) are not needed. Supplemental oxygen is generally administered during, but not prior to, the procedure (D).

A young adult male is brought to the emergency room with multiple gunshot wounds in the chest, abdomen, and head. After collecting the client's blood-saturated clothing as forensic evidence for the medical examiner, which action should the nurse implement? a. Fold clothing in a large specimen container and send to the pathology lab. b. Roll the clothing in a towel and cover it with an impermeable drape. c. Place the clothes in a paper bag and transfer bag to a red biohazard bag. d. Drop the clothes in a red plastic bag and maintain blood-borne precautions.

ANS: C The client's clothes are vital pieces of forensic evidence that reveal bullet entrance, exit, range of fire, gun soot, as well as blood DNA, so saturated clothing should be placed in a paper bag, which allows air to dry the blood and preserves DNA evidence. The chain of custody should be maintained (A) until the nurse gives the evidence (clothing) to a law enforcement officer. The clothes should be folded, not rolled (B), to preserve gun soot and other markings that define the bullet entry site. A plastic bag (D) contributes to mold formation, which degrades DNA as time lapses between transport, storage, and forensic analysis.

A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures? a. Chorionic villi sampling under ultrasound. b. Amniocentesis and fetal monitoring. c. Ultrasonography and nonstress test. d. Oxytocin challenge test and fetal heart rates.

ANS: C The nurse should prepare the client for a non-stress test (NST), which consists of fetal monitoring to evaluate fetal heart rate acceleration in response to fetal movements, and ultrasonography, which measures fetal breathing movements, gross body movements, and amniotic fluid volume. (A and B) are invasive procedures that require intrauterine sample collection. (D) measures the fetus's ability to tolerate the stress of labor by simulating uterine contractions and evaluating for late decelerations, a non-reassuring sign. The most non-invasive testing should be done first.

A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement? a. Increase the intake of salty foods. b. Administer NaCl supplements. c. Restrict oral fluid intake. d. Hold the client's loop diuretic.

ANS: C The oral fluid intake (C) should be restricted. The kidney's sodium regulation mechanisms keep the serum sodium level stable (normal is 134 to 145 mEq/L). A serum sodium level of 128 mEq/L indicates hyponatremia, usually associated with an excess fluid level, evidenced by neck vein distention and lung crackles. The client needs a fluid restriction (C) rather than an increased intake of sodium (A and B), which may further increase the fluid retention. Diuretics help the client excrete the excess fluid, which is a desirable effect (D).

An 85-year-old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation? a. This is sexual harassment and needs to be reported to the administration immediately. b. The UAP needs to be reassigned to another group of residents, preferably females only. c. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need. d. The resident needs to know the rules concerning unwanted touching of the staff and the consequences.

ANS: C The resident may feel isolated and is likely to be demonstrating his unmet need for touching (C). Often older men are wrongly accused of sexual advances when they demonstrate needs for touch (A). The UAP needs to be taught appropriate means of handling the situation, but (B) is avoiding the situation and is not a good management technique. The resident should not be given consequences when he has not done anything seriously wrong (D).

A nurse is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information? a. Disease registry. b. Department of Health. c. Bureau of Vital Statistics. d. Census data.

ANS: C The state's Bureau of Vital Statistics (C) tracks demographic data, including infant death rates. (A) provides centralized data regarding specific diseases, usually a compilation of statistical data on cancer and heart disease. A state's Department of Health is not required to compile infant death rate statistics (B). Census takers do not record vital statistics such as infant death rates (D).

A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Before being discharged, the nurse should provide the client with what instruction? a. Keep the left leg in a dependent position. b. Apply heat to the left leg cast. c. Do not attempt to scratch the skin under the cast. d. Apply a cold pack to any "hot spots" on the cast.

ANS: C Trying to scratch the skin under the cast (C) may cause a break in the skin and result in the formation of a skin ulcer. Cool air from a hair dryer may alleviate an itch. The affected leg should be elevated to help decrease edema (A). Ice bags or cold application devices should be placed on each side of the cast to help decrease edema and pain (B). "Hot spots" (D), or warm spots on the cast, may indicate infection and should be reported to the healthcare provider immediately.

The nurse-preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify? a. Warm skin, hypertension, and constricted pupils. b. Bradycardia, hypotension, and respiratory acidosis. c. Mottled skin, tachypnea, and hyperactive bowel sounds. d. Tachycardia, mental status change, and low urine output.

ANS: D (D) includes the earliest signs and symptoms of shock. Decreased tissue oxygenation in early shock first affects the brain, which is dependent on a high concentration of oxygen for optimum functioning. The earliest signs of shock include mental status changes accompanied by subtle cardiovascular compensatory mechanisms, including tachycardia, which increases blood flow to the organs, and reduces volume excretion through the kidneys, thereby conserving the body's circulatory volume. (A, B, and C) do not describe early symptoms of shock, although several of these symptoms occur in later stages of shock.

A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse? a. Is unable to feel sensation in the arms and hands. b. Has flaccid upper and lower extremities. c. Blood pressure is 110/70 and the apical pulse is 68. d. Respirations are shallow, labored, and 14 breaths/minute.

ANS: D A C-5 injury can result in edema ascending the spinal cord, which can result in the absence of breathing, so altered respiratory status should be reported immediately (D). (A and B) are expected findings in a client with a C-5 spinal cord injury. (C) is within normal limits and does not require intervention by the nurse.

Which finding should raise the greatest concern for a nurse who is performing an ENT examination? a. A painful ulcerated mucosal area inside the cheek for 1 day. b. Stippled gingival margins that adhere firmly to the teeth. c. A number of small yellowish-white and raised lesions on the buccal mucosa. d. An ulceration under the tongue that has been present for the last three weeks.

ANS: D A prolonged ulceration (D) is indicative of cancer and should be investigated further. A mucosal ulceration of short standing (A) should be watched for evidence of healing. (B) is an expected finding and (C) is an expected variation.

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client: a. admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl. b. with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch. c. post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube. d. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.

ANS: D A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to 100 and should be assessed immediately (D). (A) is an expected finding. (B) is not an unusual finding. (C) is an expected finding for this client.

The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene? a. An Asian-American mother reports using cupping to treat infection, resulting in a pattern of red round marks on her toddler's back. b. A Hispanic pregnant client who is often late for appointments, arrives late for today's appointment. c. A Native-American who is being interviewed will not make direct eye contact when asked about violence in the home. d. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit.

ANS: D African-Americans are more prone to lactose intolerance, and further assessment is needed to determine if the infant in (D) should be switched to a soy-based formula. A common treatment for fevers and infections among Asians is cupping, which leaves red marks on the back and does not harm the child (A). Hispanics tend to be present-oriented, and being late for an appointment is not a significant factor to them (B). Native-Americans consider direct eye contact distasteful or disrespectful (C).

In assessing a 70-year-old female client with Alzheimer's disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care? a. Scrub the lesions with warm soapy water. b. Encourage the client to drink orange juice for added vitamin C. c. Notify the healthcare provider of the need for oral antibiotics. d. Ensure that the client gets adequate B vitamins in foods or supplements.

ANS: D Angular stomatitis at the corners of the mouth is caused by poor dietary intake of vitamin B2 (riboflavin) and B6 (pyridoxine) (D). (A) would irritate them. Although a vitamin C supplement would be beneficial, (B) would burn the client's mouth and make her less likely to eat. The client is not likely to have an infection, but if the cracks at the corners of her mouth do become infected, antibiotics in the form of a cream would be more appropriate (C).

A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant? a. Ampicillin (Omnipen) 25 mg/kg slow IV push. b. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV. c. Digoxin (Lanoxin) 20 micrograms/kg IV. d. Beractant (Survanta) 100 mg/kg per endotracheal tube.

ANS: D Beractant (D), a lung surfactant, should first be given 15 minutes to 8 hours after birth. RDS (respiratory distress syndrome) results primarily from immature lungs and the lack of surfactant (a surface-active lipoprotein mixture that coats the alveoli and prevents their collapse at the end of respiration). (A and B) would be indicated if sepsis was suspected, but are not specific for the premature infant. The infant's heart rate is within normal limits, so (C) would not be indicated.

The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother? a. The child can be around other children but should wear a mask at all times. b. The child will no longer be contagious, no need to take any further precautions. c. Make sure there are no children under the age of 6 months around the infected child. d. Do not expose other children. RSV is very contagious even without direct oral contact.

ANS: D Children with RSV should not expose other infants (D) to the virus. RSV is the most prevalent respiratory pathogen found in infancy and early childhood, is an especially contagious virus because it can live on surfaces outside the body for hours, and is easily passed from person to person without the need for direct oral contact. (A) does not ensure that the virus is not be passed to other children and it is impossible to keep a mask on an infant. (B) is incorrect. The child is still contagious. Even though RSV peaks at 2- to 6- months of age, older infants and toddlers are susceptible (C).

Which client's laboratory value requires immediate intervention by a nurse? a. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams. b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday. c. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value. d. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday.

ANS: D Clients undergoing chemotherapy (D) are at particular risk for neutropenia. The healthcare provider must be notified of the downward trend and precautions must be taken. Clients with neutropenia (an absolute count of neutrophils less than 2,000) are prone to infections and those with agranulocytosis (an absolute count less than 500) may have a rapid progression to fatal sepsis. (A) is currently being treated with the transfusion. (B) often experiences elevated glucose levels, and sliding scale coverage does not usually occur until the level reaches 200 mg/dl. (C) is an expected finding with hepatitis, which is why the client is jaundiced.

A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. Encourage him to initiate daily rituals. b. Reinforce the reality of his financial situation. c. Direct him to drink a glass of red wine at bedtime. d. Teach him to limit sugar and caffeine intake.

ANS: D Clients who experience high levels of anxiety should be instructed to limit intake of caffeine and sugar (D) because both are central nervous system (CNS) stimulants. (A) is a symptom of anxiety and should not be encouraged. (B) is essentially arguing with the client. Alcohol (C) should not be used for treating anxiety.

The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? a. Pedal pulses. b. Breath sounds. c. Gag reflex. d. Vital signs.

ANS: D Life-threatening complications such as hypovolemia and sepsis can occur following a paracentesis, and measurement of vital signs (D) will provide assessment data that will help detect the occurrence of such complications. (A) might be assessed to check for circulation in the lower extremities, but are not indicated for postparacentesis assessment. Reduction of (B) may occur as the result of decreased fluid in the peritoneal cavity, but is a desired outcome, not a complication, of this procedure. (C) is not affected by a paracentesis procedure.

The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, "The pills don't seem to be working. They are not helping the pain at all." Which factor should influence the nurse's response? a. Noncompliance is probably affecting optimum medication effectiveness. b. Drug dosage is inadequate and needs to be increased to four times a day. c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream. d. NSAID response is variable and another NSAID may be more effective.

ANS: D Response to particular NSAIDs is highly individual (D), so switching to another NSAID may provide better pain relief. There is no indication of (A). Drug effects are immediate (C). Recommended doses (B) for adults are 250 to 500 mg twice a day. If the dosage is increased it is not done by increasing dose frequency.

A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client? a. Disturbed thought processes. b. Altered sleep pattern. c. Imbalanced nutrition: less than. d. Risk for injury.

ANS: D Safety is the priority nursing problem because clients with dementia are not cognitively aware of potential dangers (D). (A, B, and C) are also indicated for this client, but they are not priorities over safety.

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the most likely reason for the nurse's behavior? a. The nurse is stating disapproval of the statement. b. The nurse is respecting the client's loss. c. Silence is reflecting the client's sadness. d. Silence allows the client to reflect on what was said.

ANS: D Silence (D) offers the client a moment for reflection and allows the nurse to demonstrate respect for the client. Silence does not indicate (A or B), but rather feelings related to the loss. Silence alone does not signify sadness (C).

Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome? a. Husky voice and complaints of hoarseness. b. Warm, soft, moist, salmon-colored skin. c. Visible swelling of the neck, with no pain. d. Central-type obesity, with thin extremities.

ANS: D The classic picture of Cushing's syndrome in the adult is central-type obesity with thin extremities (D), along with a "buffalo hump" in the supraclavicular area, heavy trunk, and thin fragile skin. The symptoms described in (A) are clinical manifestations of hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a goiter or a tumor of the thyroid gland.

A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate? a. Bounding erratic pulse. b. Regularly irregular pulse. c. Thready irregular pulse. d. No palpable pulse.

ANS: D The client would have no palpable pulse (D), because ventricular fibrillation is chaotic electrical activity which does not produce cardiac output. This is a medical emergency which requires immediate treatment to prevent death. (A, B, and C) are not typical of pulses in ventricular fibrillation.

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? a. Administer an antiemetic before starting the chemotherapy. b. Instruct the client to drink plenty of fluids during the treatment. c. Keep the head of the bed elevated until the treatment is completed. d. Monitor the client's intravenous site hourly during the treatment.

ANS: D The nurse must monitor the site frequently (D). Extravasation occurs when a vesicant such as chemotherapy infiltrates the tissue surrounding the intravenous site. To decrease this risk, the nurse must monitor the intravenous site frequently. (A, B, and C) will not decrease the risk of extravasation.

A nurse is completing the health history for a 25-year-old male client who reports that he is allergic to penicillin. Which question should the nurse ask after receiving this information? a. "Are you allergic to any other medications?" b. "How often have you taken penicillin in the past?" c. "Is anyone else in your family allergic to penicillin?" d. "What happens to you when you take penicillin?"

ANS: D The nurse needs to obtain information about the client's specific reaction to the agent (D) to determine whether an allergy exists or whether the reaction is a medication side effect. (A, B, and C) have little relevance to obtaining pertinent information for this client's health history.

A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? a. Administer sargramostim (Leukine, Prokine). b. Infuse PRBC and platelet transfusions. c. Give parental prophylactic antibiotics. d. Maintain a protective isolation environment.

ANS: D The priority intervention for a client who is pancytopenic while receiving BMT is to ensure that a protective isolation environment is maintained (D). After high dose chemotherapy with or without irradiation, the client remains immunosuppressed during rescue of the hematopoietic system and is highly susceptible to bacterial, fungal, and viral infections. Although (A, B, and C) are vital components of the treatment regimen, basic environmental precautions are critical in preventing exposure to organisms, with resulting infection.