N487 Leadership in Nursing: NCLEX Review for Quiz Ch 8-12

What is an allergic reaction that can quickly deteriorate into shock and death? 1. Anaphylaxis 2. Graft-versus-host disease 3. Type III, immune complex formation 4. Delayed sensitivity

1 Anaphylaxis is a massive antigen-antibody response, causing a physiologic system shutdown and possible death. Graft-versus-host disease (GVHD) occurs when antibodies in the transplanted organ attack the host's antigens. An immune complex formation occurs when antigen-antibody complex is deposited in body tissue. A delayed sensitivity is a reaction that occurs after cells are sensitized to an antigen, as seen in the tuberculosis skin testing. (Lewis et al., 10 ed., pp. 197-199)

The physician orders an IV piggyback of cefotetan 1 gm in 100 mL D5W to run over 30 minutes. The drop factor for the tubing is 10 gtt/mL. At what rate in drops per minute would you run the IV? 1. 33 gtt/min 2. 25 gtt/min 3. 12 gtt/min 4. 50 gtt/min

1 The calculation would be 100 mL/30 min x 10 gtt/mL = 33.0 or 33 gtt/min. (Potter & Perry, 9 ed., pp. 618-620)

A client with AIDS has several cutaneous lesions identified as Kaposi sarcoma. How will the nurse care for these areas? 1. Gently cleanse the areas, keeping them dry and free of abrasions. 2. Place sterile, saline-soaked gauze over the areas. 3. Apply a topical corticosteroid cream. 4. Decrease infection by applying an antibiotic ointment.

1 There is no specific nursing care required for Kaposi sarcoma lesions. Gently cleansing the area and protecting it from abrasive trauma, which could open the lesions, would be appropriate. Dressings, steroid cream, and antibiotic ointment are not indicated. Standard precautions should be followed when caring for the lesions. (Lewis et al., 10 ed., pp. 222-223)

The nurse is assessing a client after beginning external radiation. What is a nursing observation that confirms the presence of early side effects of the radiation? 1. A gradual weight loss and GI disturbances 2. Skin erythema followed by dry desquamation 3. Vertigo when sitting up quickly 4. Excoriation and blisters on the affected skin

2 Abnormal skin pigmentation, erythema, and dry desquamation may develop within a few days of beginning the radiation treatment. Wet desquamation may occur with progression of the radiation treatment, but the skin does not have blisters. Vertigo may be a sign of orthostatic hypotension associated with hypovolemia. The weight loss occurs, but it is not due to the radiation; it is most often due to the malignancy. (Lewis et al., 10 ed., pp. 250-256)

The nurse is caring for a client who is experiencing a severe anaphylactic reaction caused by an allergy to peanuts. After administering subcutaneous epinephrine and beginning oxygen administration, what would be the next most important nursing action? 1. Administer analgesics to relieve the pain. 2. Start an IV for fluid administration. 3. Insert a catheter to determine urinary output. 4. Obtain a history of possible reactions to penicillin.

2 Shock is a common problem in anaphylactic reactions; therefore it is important to establish an IV for fluid and medication administration. There should be no pain, and there is no reason the client cannot void on his or her own. A history can be taken at a later time. (Lewis et al., 10 ed., p. 202)

Which of the following signs and symptoms would the nurse assess for in a client with possible lithium toxicity? 1. Hypotension, bradycardia, polyuria 2. Tachycardia, hypertension, convulsions 3. Diarrhea, ataxia, seizures, lethargy 4. Urinary frequency, vomiting, fever

3 Lithium toxicity is a serious problem for clients with bipolar disorder. Symptoms include diarrhea, confusion, ataxia, slurred speech, hypotension, seizures, oliguria, coma, and death. (Halter, 7 ed., p. 240)

The physician calls the unit and leaves an order for a client. The order is for cefaclor 0.1 gm PO. The dose available in the unit is 125 mg/5 mL. How many milliliters will the nurse give? Answer: __________ mL

4 mL Rationale: 1 gm = 1000 mg; therefore, 0.1 gm = 100 mg 125 mg : 5 mL :: 100 mg : x mL

A client is receiving busulfan. The nurse would notify the physician regarding which assessment finding? 1. Persistent, nonproductive, dry cough 2. Hemoglobin 13 g/dL (130 g/L), hematocrit 38% (0.38 proportion of 1) 3. Nausea and vomiting 4. Low serum uric acid

1 Pulmonary toxicity (dry nonproductive cough, crackles, dyspnea, tachypnea) is an adverse effect of busulfan. It can lead to pulmonary fibrosis. Hemoglobin is within normal limits. The nausea and vomiting may be a side effect of the chemotherapy, and the client would be treated for this. Problems occur with a high (not low) serum acid level. (Lehne, 9 ed., p. 1226)

A client is scheduled for a total hip replacement, and he has a history of using several herbal and vitamin products. What would the nurse advise the client to discontinue at least 2 weeks before surgery? Select all that apply. 1. Garlic 2. Vitamin C 3. Ginger root 4. St. John's wort 5. Ma huang 6. Black cohosh

1, 3, 5 Garlic and ginger root can prolong bleeding time by suppressing platelet aggregation. Ma huang is ephedra and affects the blood pressure. St. John's wort, vitamin C, and black cohosh are safe to continue before surgery. (Burchum & Rosenthal, 9 ed., pp. 1321-1328)

The nurse is caring for a client who had a stroke (brain attack) 3 months ago and is taking warfarin 5 mg by mouth (PO). The client tells the nurse she has started taking some herbal and vitamin supplements. She gives the nurse a list of the supplements she is taking. What supplements would cause concern for the client who is on warfarin? Select all that apply. 1. Garlic 2. Cyanocobalamin (vitamin B12) 3. St. John's wort 4. Vitamin E (alpha tocopherol) 5. Saw palmetto 6. Ginkgo biloba

1, 4, 6 Garlic, ginkgo biloba, and vitamin E may interfere with platelet aggregation and increase the risk for bleeding in clients who are taking warfarin. (Burchum & Rosenthal, 9 ed., pp. 1321-1324)

What is an important aspect of client teaching regarding external radiation therapy? 1. Remain isolated after treatments. 2. Fast before the treatment. 3. Schedule treatments monthly. 4. Leave skin markings between treatments.

4 Skin markings are used by the radiotherapist to delineate the exact area of the body to be irradiated. Treatments are completed in a series, depending on the location of the malignancy and the level of radiation being administered. The treatments do not require isolation, fasting, or any form of activity restriction. (Lewis et al., 10 ed., pp. 249-250)

The nurse is preparing medications for a client. The medication order is for cefaclor 0.1 gm PO. The dose available in the unit is 125 mg/5 mL. How many milliliters will the nurse need to give? Answer: __________ mL

4 mL 1 gm 5 1000 mg; therefore, 0.1 gm 5 100 mg 125 mg : 5 mL :: 100 mg : x mL (Potter & Perry, 9 ed., pp. 618-620)

The nurse is working in the pediatric unit and receives a phone order from the doctor for a 10-year-old client who weighs 40 kg. The order is for ceftazidime 1.5 gm every 8 hours IV. The therapeutic dosage range is 90 to 150 mg/kg/24 hr. What would be the best nursing action? 1. Administer the medication because it is within the therapeutic dosage range. 2. Call the doctor to clarify the order because it is outside the therapeutic dosage range. 3. Call the hospital pharmacist and ask him or her to calculate the dosage. 4. Notify the nursing supervisor and request assistance.

1 Administer the medication ceftazidime as ordered. The therapeutic dosage is 90 to 150 mg/kg/day. Ordered: 1.5 gm every 8 hours 5 1.5 gm 3 3 doses 5 4.5 gm per day Minimum therapeutic dose: 90 mg 3 40 kg 5 3600 mg or 3.6 gm per day Highest safe dose: 150 mg 3 40 kg 5 6000 mg or 6 gm per day (Potter & Perry, 9 ed., p. 620)

The nurse recognizes which of the following conditions as an oncologic emergency? Select all that apply. 1. Cardiac tamponade 2. Leukopenia 3. Syndrome of inappropriate antidiuretic hormone 4. Hypercalcemia 5. Hypophosphatemia 6. Tumor lysis syndrome

1, 3, 4, 6 Metabolic emergencies, including SIADH, hypercalcemia, and TLS; infiltrative emergencies, including cardiac tamponade; and obstructive emergencies are life-threatening complications of cancer or cancer therapy. Leukopenia is an expected side effect. Hypophosphatemia is not common. (Lewis et al., 10 ed., p. 263)

A client is receiving chemotherapy with several antineoplastic agents. Which nursing observation is considered a common side effect of chemotherapy? 1. Slow, slurred speech 2. Increased leukocytes on complete blood count 3. Stomatitis and oral ulcers 4. Sinus dysrhythmias with bradycardia

3 A common side effect of chemotherapy is stomatitis. It may be manifested as inflammation of the gums and ulcerations in the mouth. There is a decrease in leukocytes, making the client less resistive to infection. Dysrhythmias are not common in cancer therapy; they may occur with electrolyte imbalances secondary to chemotherapy. The slowed speech may occur with hypercalcemia as a complication involving the parathyroid gland. (Lewis et al., 10 ed., pp. 250-256)

An older adult client has a prescription for continuous fluid replacement at 75 mL/hr. The nurse is preparing to start the IV. Which option would be best? 1. A 22-gauge butterfly needle, right arm antecubital area. 2. An 18-gauge, 3-inch IV cannula, inserted in the left hand. 3. An 18-gauge, 1-inch IV cannula, in the antecubital area of left arm. 4. A 22-gauge, 1-inch IV cannula, top of the left hand.

4 With a continuous flow at 75 mL/hour, a small-gauge IV cannula (22 G), 1 inch (2.5 cm) is appropriate. Butterfly needles are used for short-term infusions and drawing blood. IVs should be started in the lowest vein possible and progress upward. The antecubital area is not a preferred area. (Potter & Perry, 9 ed., p. 958)

The doctor has indicated that ampicillin and gentamicin are to be given piggyback in the same hour, every 6 hours (12-6-12-6). How would the nurse administer these drugs? 1. Combine the drugs into 100 mL NS and administer. 2. Give each drug separately, flushing between drugs. 3. Retrograde both drugs into the tubing. 4. Give one drug every 4 hours and the other every 6 hours.

2 Only one antibiotic should be administered at a time; therefore if the medications are given during the same hour, the IV tubing will need to be flushed between administrations. Both drugs should be administered at the time ordered. (Potter & Perry, 9 ed., pp. 667-670)

The nurse is preparing to administer an intramuscular injection to an infant who is 8 months old. Which muscle would be the most appropriate injection site? 1. Deltoid 2. Dorsogluteal 3. Vastus lateralis 4. Ventrogluteal

3 The vastus lateralis is the preferred site for an infant because the muscle is not located near any vital nerves or blood vessels. It is the best choice for IM injections for children younger than 3 years of age. The deltoid muscle has too little muscle mass in a young infant 2 or toddler and is unable to hold large injected volumes of medication. (Hockenberry & Wilson, 10 ed., p. 917)

A client is experiencing difficulty breathing, periorbital swelling, flushing, and itching. He had a diagnostic test in which an iodine-based dye was used about an hour earlier. What medication will the nurse anticipate administering immediately? 1. A bronchodilator such as aminophylline 2. A corticosteroid such as dexamethasone 3. An antihistamine such as diphenhydramine 4. An adrenergic agonist such as epinephrine

4 Epinephrine, given subcutaneously or intravenously, is the drug of choice for anaphylactic reactions. The reaction described is a mild to moderate anaphylactic reaction. The other medications listed may be used in treatment of the reaction, but epinephrine is the immediate drug of choice. (Lewis et al., 10 ed., pp. 202-203.)

The nurse is caring for a client who is categorized as HIV positive, acute infection. What would the nurse anticipate finding on the nursing assessment? 1. Fever, swollen lymph glands, nausea 2. Confusion, wasting syndrome, localized infections 3. Dyspnea, dementia, persistent fever 4. Night sweats, low-grade fever, generalized lymphadenopathy

1 An acute infection occurs when the primary condition is identified or the client has recently been infected. The client may be asymptomatic at this time or they may have flulike symptoms and early nonspecific changes characterized by fatigue, sore throat, fever, diarrhea, muscle and joint pain, diffuse rash, and swollen lymph glands. The other items are symptoms noted with chronic HIV infection. Chronic HIV infection can be either asymptomatic (fatigue, headache, low-grade fever, night sweats, persistent generalized lymphadenopathy), symptomatic (symptoms become worse, leading to persistent fever, frequent drenching night sweats, chronic diarrhea, recurrent headaches, and fatigue severe enough to interrupt normal routines with localized infections, lymphadenopathy, and nervous system problems), or AIDS (development of opportunistic infections, wasting syndrome, dementia). The symptoms noted in the remaining options are seen with chronic disease. (Lewis et al., 10 ed., pp. 220-221)

The nurse is about to conduct an admission assessment on an 85-year-old female client who is admitted after falling down in her home. When determining the amount of time to set aside for the interview, the nurse will consider which of the following? 1. Allow ample time to gather psychosocial data from the client. 2. Skip the psychosocial assessment; it is not important for the client with a physiologic problem. 3. Interview the client's daughter and son about the client's psychosocial background. 4. Ask the client whether she has any pressing or major issues she wants to talk about.

1 Because older adult clients may be starved for someone to listen to them, the nurse must allow ample time to gather psychosocial data. It would not be good nursing judgment to skip the psychosocial assessment. The nurse should interview the client and, if additional information is required, then the client's family can be interviewed. Although asking the client about pressing or major issues is a good answer, it does not address the importance of allowing sufficient time to actually discuss the pressing or major issues that the client may want to describe. (Potter & Perry, 8 ed., pp. 318-319)

The nurse is caring for a client with excess fluid volume. Which action will best evaluate a change in the client's condition? 1. Obtaining the client's daily weight before breakfast each day 2. Measuring fluid intake and output and comparing with values from the previous day 3. Assessing the blood pressure and comparing it with previous readings 4. Auscultating the lungs for the presence of adventitious breath sounds

1 Daily weights are an accurate indicator of fluid retained or lost. One liter of fluid is equal to 2.2 pounds (1 kg). Measuring the intake and output does not take into consideration insensible fluid loss and is not as accurate an evaluation as is the daily weight. Changes in vital signs are less reliable because they do not reflect subtle changes in retention of fluid. Although adventitious sounds may be present if the client is overhydrated, the daily weights would have increased before the pulmonary changes occurred. (Lewis et al., 10 ed., p. 277.)

When caring for a client admitted for medically monitored detoxification from alcohol, the nurse would assess for which of the following signs and symptoms of withdrawal? 1. Anorexia, irritability, nausea, and tremulousness 2. Bradycardia, hypotension, diaphoresis, and fever 3. Vivid hallucinations, coarse irregular tremor 4. Severe craving, euphoria, profuse sweating, and paranoid ideation

1 Detoxification or controlled withdrawal from alcohol via a medical protocol includes regular assessment for withdrawal signs and symptoms and administration of prescribed medications. Signs and symptoms of alcohol withdrawal include anorexia, irritability, nausea, tremulousness, insomnia, nightmares, hyperalertness, tachycardia, increased blood pressure, diaphoresis, and anxiety. (Halter, 7 ed., p. 421)

Which of the following nursing interventions should be instituted for a client experiencing a manic episode? 1. Place the client in a quiet area, separate from others. 2. Encourage the client to engage in some physical activity. 3. Establish firm, set limits on behavior. 4. Include the client in the group's activities.

1 For the client's protection, he should be moved to a quiet environment away from others. This will help him regain some control and will not produce unneeded stimuli. Setting firm limits would be appropriate for manipulative behavior. Until the manic behavior is under control, including a client in group activities (physical or otherwise) would not be therapeutic for him and would more than likely be disruptive to others. (Halter, 7 ed., p. 237)

A client is being referred to the hospice nurse for care. The nurse explains to the client and the family that the primary goal of hospice differs from the goal of traditional care in what way? Hospice care: 1. Provides support to the family and to the client with a terminal illness 2. Is delivered only at home, so that no extraordinary means are initiated to prolong life 3. Provides a Medicare-supported pain regimen so pain medications are affordable 4. More readily recognizes advance directives related to the "right to die"

1 Hospice care provides compassion, concern, and support for the dying client and family. It may or may not be delivered in the home. Pain control is an issue for the hospice client and for any client with cancer. Advance directives are recognized in all health care settings. (Potter & Perry, 9 ed., pp. 761-762)

A client is diagnosed with an immunodeficiency disease. The nurse would understand what is characteristic of this condition? 1. Occurs when a client's body is unable to defend itself from an invading microorganism 2. Creates a severe, sudden problem that is characterized by increased vascular permeability 3. Is precipitated by the destruction of the normal lymphocytes in the attempt to reduce the serum level of the antigen 4. Is a condition in which the normal immune response is interrupted and the body cells do not recognize healthy tissue

1 Immunodeficiency is the condition when the immune system is depressed, weak, or compromised and is unable to defend the body from invading microorganisms. Immunodeficiency may be primary if it is caused by an absence of immune cells or by poorly developed immune cells. It is secondary if it is caused by illnesses or treatment. A severe, sudden problem characterized by increased vascular permeability describes an anaphylactic reaction. The destruction of normal lymphocytes in the attempt to reduce the serum level of the antigen reflects phagocytosis as the white cells destroy the foreign protein. When the normal immune response is interrupted and body cells do not recognize healthy tissue, this is characteristic of an autoimmune condition. (Lewis et al., 10 ed., pp. 205-206)

The nurse is assisting a client with his antiretroviral therapy. What can the nurse do to help the client take his medications as prescribed? 1. Assess the client's activities of daily living and his lifestyle routine to determine when he can most easily remember to take his medications. 2. Provide the client with brochures that explain the side effects of the medications and why it is so important for him to adhere to his medication schedule. 3. Plan for him to visit with other clients who use the same antiretroviral therapy and have them explain to the client how they handle their medications. 4. Emphasize to the client how important it is to take the medications on the schedule prescribed so that the virus will not get stronger.

1 It is important to identify the client's routines and discuss how he can adapt those routines to take his medications as prescribed. Discussing with the client the importance of taking the medications does not assist him to identify ways in which he can incorporate the medications into his daily routines. Talking to and working with another client is positive, but it still does not incorporate the medication routine into his own daily living routines. (Lewis et al., 10 ed., pp. 228-229)

The nurse is assessing an IV site after the client has verbalized an increase of tenderness. The site is inflamed, streaks of inflammation are progressing up the inside of the client's arm, and the fluid is continuing to infuse at the prescribed rate. What is the best nursing action? 1. Remove the catheter and place warm packs on the area. 2. Lower the IV bag below the site to determine whether there is blood return in the line. 3. Determine what medications the client is receiving that may have caused the irritation. 4. Decrease the rate of the infusion to decrease the discomfort.

1 Phlebitis has developed at the site, and the catheter should be removed. If continued administration of fluids is necessary, the catheter should be restarted at another site. It does not make any difference whether the catheter is still in the vein. The catheter must be removed because of the inflammation. Assessment of medications causing the problem can be done at a later time after the current problem is resolved. The rate of infusion should remain the same. (Potter & Perry, 9 ed., p. 962)

The nurse is reviewing the health care provider's prescriptions for a new client returning from the post anesthesia care unit. The client is NPO, with a nasogastric tube and stable vital signs. Which prescription should the nurse question? 1. 20 mEq potassium IV push. 2. 1000 mL D5 1⁄2 NaCl to infuse at 125 mL/hr. 3. Assist client to dangle at bedside in morning. 4. Mefoxin 1 gm IV in 50 mL D5W over 30 minutes.

1 Potassium should never be administered by IV push. It is extremely irritating and painful at the catheter site, as well as lethal to the client when administered by IV push. It should be diluted in an IV solution and run over the time of the total infusion (1000 mL D5W with 40 mEq potassium over 8 hours), or small amounts should be given in less solution (potassium 10 mEq in 250 mL D5W to run over 3 hours). The other orders listed are all within acceptable limits for a postoperative client. (Lewis et al., 10 ed., p. 282)

A client has pain at the peripheral IV site. The nurse determines the IV is not infusing; assesses the site; and finds the area swollen, pale, and cool to touch. What is the best nursing action? 1. Discontinue the IV and apply warm, moist packs to the involved area. 2. Slow the IV infusion and see whether the swollen area decreases. 3. Notify the health care provider regarding the status of the IV. 4. Discontinue the IV and start another IV in the same vein, distal to the current site.

1 The IV is infiltrated and should be discontinued. A warm, moist pack can be applied for client comfort. The IV should be discontinued but not restarted distal to the previous site; it should be started proximal to or above the current infiltrat

The nurse is reviewing the chart of a client who recently had a cervical biopsy. The test results indicate Tis, N0, M0. How will the nurse interpret this information? 1. The cancer is in situ, which means it is localized and not invasive at this time. 2. The origin of the cancer is probably in the uterus, and further testing will be necessary. 3. The lymph nodes are involved, and the presence of distant metastasis cannot be determined. 4. There is no cancer present; the tissue was normal.

1 The cancer is in situ (Tis), which means the cancer is localized to the cervix; there is no evidence of either lymph node involvement (N0) or of invasive activity (M0). Because it is not invasive at this time, there is no immediate need for treatment. The client's history and risk factors will influence the decisions for further diagnostic testing or treatment. (Lewis et al., 10 ed., p. 241)

A nurse is caring for a client who received a penicillin injection about 15 minutes earlier. The client complains of itching around the mouth, and this rapidly progresses to severe dyspnea and respiratory distress. What are the priority nursing actions? 1. Anticipate need for possibility of endotracheal intubation, begin oxygen, call for assistance, and obtain emergency cart. 2. Place the client in supine position and assess for patent airway and presence of breath sounds. 3. Start oxygen at 6 L/min via nasal cannula; review chart for history of a penicillin allergy. 4. Place the client in semi-Fowler's position, perform a chin lift to open the airway, and assess for air movement.

1 This situation best describes an anaphylactic reaction to the penicillin injection. This is a rapidly occurring response that may result in a life-threatening occlusion of the airway (laryngeal edema, bronchospasm). The client may require an emergency tracheotomy or endotracheal intubation. Time should not be wasted on checking the chart or further assessment. The client is obviously in distress, and the presence of breath sounds will not be significant in determining the nursing actions. The chin lift is not an effective method for opening an airway that is occluded from edema or bronchospasm. Epinephrine is the drug of choice for a serious anaphylactic reaction. (Lewis et al., 10 ed., p. 201)

At the shift hand-off report, a nurse is told that one of her clients is becoming tolerant to his pain medication. What nursing observation would be in agreement with this conclusion? 1. The current medication order, which has previously been effective, is no longer providing adequate pain relief. 2. The client becomes irritable and confused before the next scheduled dose of medication. 3. Pain medication is being administered every 3 to 4 hours around the clock for adequate pain relief. 4. The client is sleeping and arouses with physical and verbal stimulation but is very lethargic.

1 Tolerance occurs when there is a decrease in the response to a drug after repeated drug administration. More of the analgesic is needed to maintain the same level of pain control. Requiring pain medication around the clock for adequate pain relief is not tolerance because the client is obtaining proper pain relief. Irritability and confusion before the next dose may be an adverse reaction to the medication, or another problem may be occurring. Sleepiness and lethargy may indicate that the client is overmedicated. (Burchum & Rosenthal, 9 ed., pp. 74-75)

A client is admitted to the inpatient psychiatric unit for medically monitored detoxification from alcohol. Which of the following actions would be included in the client's plan of care? 1. Encourage increased fluid intake. 2. Order a high-protein, high-fat diet. 3. Provide a high-sodium, low-carbohydrate diet. 4. Encourage ambulation and deep breathing.

1 When assisting in the medical treatment of alcohol withdrawal, the nurse should encourage intake of fluids. Alcohol depletes the body of fluid, and detoxification is usually smoother if the client takes fluids readily. A high-protein and high-carbohydrate diet would be encouraged, because alcoholic clients often have poor nutrition and become debilitated. (Halter, 7 ed., p. 421)

The nurse is assisting a client to ambulate. Upon standing at the bedside, the client becomes weak, says "I feel dizzy," and sits back down on the bed. What should be the nurses next action? 1. Lay the client down in bed. 2. Obtain a blood pressure. 3. Ask the client to try again. 4. Find additional help for ambulation.

1 With dehydration or fluid deficit, orthostatic hypotension may occur. After the client is safely back in bed, the nurse should assess for other symptoms of fluid volume deficit: decreased blood pressure, weight loss, imbalance of urine output and fluid intake, and dry skin and mucous membranes. Ambulation should be avoided until the symptoms have subsided. (Lewis et al., 10 ed., p. 282)

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client? Select all that apply: 1. Use active listening skills to seek information from the client. 2. Encourage the client to describe the problem as she sees it. 3. Ask the client to tell you exactly what she thinks is happening. 4. Tell the client that she is delusional and you can help her. 5. Explain to the client that most people are not investigated by the CIA or FBI. 6. Reassure the client that you are not with the CIA.

1, 2, 3 The client is demonstrating paranoid behavior, which necessitates a matter-of-fact approach that is nonjudgmental and accepting of the client's statements and shows the nurse's willingness to listen attentively to the issue. Telling the client that she is delusional, explaining that most people are not investigated by the CIA or FBI, reassuring the client that you are not with the CIA do not help the paranoid client gain trust to talk with the nurse. (Halter, 7 ed., p. 465)

A client in the emergency department has been hydrated with normal saline over the last hour for hypovolemia. Assessment changes now include a rapid bounding pulse and shortness of breath. What additional information would the nurse want to gather? Select all that apply. 1. Blood pressure 2. Level of consciousness 3. Urinary output 4. Hemoglobin level 5. Oxygen saturation

1, 2, 3, 5 The client who had been hypovolemic is not demonstrating assessment changes of fluid volume excess. Appropriate assessments include vital signs such as pulse oximetry, weight, urine output, and changes in level of consciousness. Hemoglobin would not be affected by fluid status. (Lewis et al., 10 ed., p. 277)

The nurse is documenting information regarding an IV insertion. What information is important to include? Select all that apply. 1. Time and date of insertion. 2. Type of catheter and size. 3. Name of vein used. 4. Status of fluid infusing. 5. Protective measures used. 6. Who ordered the IV and at what time.

1, 2, 4 The specific name of the vein is not necessary, but the general location of the site is important. Standard precautions are used for everyone, and it is not necessary to chart that they were used. The order and time for the IV should be on the client's chart; it is not necessary to repeat it in the documentation. The question did not ask for all the

The nurse is performing a dressing change on a client who has a Staphylococcus infection in an abdominal incision. Which infection-control precautions will the nurse implement? Select all that apply. 1. Wear clean gloves to remove the old dressing. 2. Put on a gown when entering the room. 3. Wear a face shield. 4. Dispose of the gown and mask in container outside the client's door. 5. Leave all extra dressing supplies in the room. 6. Carefully cleanse the stethoscope and scissors before taking them out of the room.

1, 2, 5 Contact precautions would require the nurse to wear clean gloves to remove the old dressing, put on a gown when entering the room, and leave all extra dressing supplies in the room. A face shield is not necessary unless splattering of fluids is anticipated. The gown and mask should be disposed of in the client's room; they should not be worn outside the room and should be disposed according to hospital policy. The stethoscope and scissors should not be taken out of the client's room. (Potter & Perry, 9 ed., p. 458)

The nurse is planning to educate colleagues on best practices in decreasing central line infections. What practices should be included in staff education? Select all that apply. 1. Follow agency policy for dressing and tubing changes. 2. Use clean technique when changing caps and dressings. 3. Report sites that are reddened. 4. Change dressings that have moisture. 5. Gauze dressings need changing less frequently

1, 3, 4 Central lines have a high rate of infection in hospitalized clients. The Centers for Disease Control and Prevention offers guidelines for prevention of intravascular catheter-related infections. The nurse should follow the agency policy for dressing and tubing changes, which will guide the nurse when in practice. Sterile technique should be used, not clean technique, and gauze dressings need to be changed more frequently, since they are porous. Moisture increases the risk of infection. All signs of infection should be reported, including temperature, increased white blood cells, and redness. (Lewis et al., 10 ed., p. 217)

Which of the following statements are correct about latex allergy? Select all that apply. 1. Typical reactions include skin redness, urticaria, and rhinitis. 2. Latex allergy involves only type I allergic reactions. 3. The more frequent the exposure to the latex, the more likely a person will develop an allergy. 4. Hand lotions should be applied before putting on gloves to reduce exposure. 5. Wash hands with mild soap after removing gloves. 6. Persons should wear a medic alert bracelet and carry an epinephrine pen.

1, 3, 5, 6 It is important for the nurse to recognize symptoms of latex allergy—skin rash, hives, flushing, and itching; nasal, eye, and sinus symptoms; asthma and (rarely) anaphylaxis. The nurse should also be aware of latex-containing products—gloves, blood pressure cuffs, stethoscopes, tourniquets, IV tubing, syringes, electrode pads, oxygen masks, tracheal tubes, colostomy and ileostomy tubes, urinary catheters, anesthetic masks, and adhesive tape. The use of nonlatex gloves and powder-free gloves, along with the elimination of oil-based hand creams or lotions when wearing gloves, can reduce exposure. Always wash hands after removing gloves. Individuals with latex allergy should wear a medic alert bracelet if latex sensitive. The more frequent and prolonged the exposure to latex, the greater the likelihood of developing latex allergy. There are two types of latex allergy: type IV allergic contact dermatitis (delayed reaction) and type I allergy reaction (immediate response). (Lewis et al., 10 ed., pp. 203-204)

The nurse is preparing discharge teaching for a woman newly diagnosed with SLE. What will be important for the nurse to include in the teaching plan? Select all that apply. 1. Wear sunscreen and protective clothing when in direct sunlight. 2. Avoid nonsteroidal antiinflammatory drugs to prevent bleeding episodes. 3. Plan activities that encourage range of motion in extremities. 4. Advise the client that pregnancy is contraindicated. 5. Observe fingertips for changes in circulation. 6. Help the client prioritize self-care activity.

1, 3, 5, 6 The client with SLE is photosensitive and needs protection from sunlight. The client needs to keep joints mobilized because of the invasion of the lupus erythematosus cells into the joints. This condition also affects the circulation in the fingertips, and Raynaud's phenomenon is characteristic of the disease. Fatigue is a problem, and the client needs to prioritize activities of daily living. NSAIDs are frequently used to reduce the musculoskeletal discomforts. Although individual disease progression and course of therapy need to be considered in consultation with health care providers, there is no specific contraindication to pregnancy. The woman should be advised regarding individual risk, but she can carry and deliver a healthy infant. (Lewis et al., 10 ed., pp. 1538-1542)

A client is receiving IV antibiotic therapy. The order is for methicillin 750 mg IV. The nurse has a vial on hand that contains 1 g. The instructions for reconstitution say to add 1.5 mL sterile water. Reconstituted solution will contain 500 mg methicillin per milliliter. How much will the nurse give? Answer: __________ mL

1.5 mL Rationale: 500 mg : 1 mL :: 750 mg : x The dosage calculation cannot be made from the amount of solution added to the vial; the ratio of mg per mL after reconstitution is 500 mg per mL. (Potter & Perry, 9 ed., pp. 618-620)

A woman explains to the nurse that she thinks she has been exposed to HIV. However, she had a test 1 week after the exposure, and the result was negative. What is most important for the nurse to explain to this client? 1. Make sure she understands the importance of safe sex practices, especially the use of condoms and contraceptive practices to prevent pregnancy. 2. Even though the client tested negative, she needs to have a series of follow-up blood tests because of the possibility of seroconversion. 3. It is important that she obtain counseling regarding the transmission of the virus and how she may protect herself and her partner. 4. The client should abstain from sexual activity for the next 3 months until the blood test confirms that she is negative for HIV.

2 After initial infection, there is a window of seroconversion in which the virus begins to replicate and produce antibodies. The client may have a negative test result early in the window. When the body begins to produce antibodies against the virus, the test result will convert to a positive. She should not get pregnant, but contraceptives (oral birth control) do not protect her against human immunodeficiency virus (HIV). Abstaining from sexual activity is frequently unrealistic, and counseling would be beneficial, but it is not the priority. Although emphasizing the importance of safe sex practices is correct, it is not the best response. The priority in this situation is the necessity for follow-up blood tests because of the initial negative test result. (Lewis et al., 10 ed., pp. 220-221; 225- 226.)

The nurse is administering medications to a client who has no allergy band on his arm. The nurse tells the client she has his penicillin medication. The client states that the last time he had penicillin, it made his mouth tingle and his hands itch. What would the best nursing action be? 1. Administer the medication because there is no indication that the client is allergic to penicillin. 2. Hold the medication and contact the physician regarding the client's statement about his previous experience with penicillin. 3. Hold the medication and review the client's chart to determine whether there is a penicillin allergy noted. 4. Notify the nursing supervisor regarding the client's statement and request further evaluation of the client.

2 Even though there is no allergy band, if the client provides information that may indicate a previous reaction to a medication (especially penicillin), hold the medication. With each exposure to an allergen, the reaction could become worse (type I reaction). Notifying the supervisor is not necessary; there is enough information for the nurse to make this decision. (Lewis, 10 ed., pp. 201-202)

To evaluate the progress of the client's systemic lupus erythematosus(SLE), the nurse evaluates which data? 1. Increased serum complement fixation, which correlates with reduction of "butterfly" rash 2. Increasing levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) 3. Overall bone marrow proliferation, which correlates with symptoms of inflammation 4. Presence of antinuclear antibodies (ANA), which correlates with a diminishing immune process

2 The ESR and the CRP are indicators of inflammation in the body. Neither is diagnostic of SLE, but the level of inflammation is an index to the progress of the condition. Presence of ANA is characteristic of SLE, but it does not indicate progression. Complement fixation does not indicate progression, nor does absence or presence of the butterfly rash. (Lewis et al., 10 ed., p. 1540)

What should the nurse take into consideration when giving medication to an older adult client? 1. The serum albumin level of an older adult is lower, thus decreasing drug metabolism. 2. The older adult client metabolizes and excretes at a decreased rate. 3. Medication affects the older adult client during the early hours of the morning. 4. Medication has an increased effect on the respiratory system of the older adult client.

2 The ability to metabolize and excrete medication decreases with the aging process. For example, at the age of 80 years, the ability to metabolize medications decreases approximately 50% compared with a 30-year-old. Medications do not have an increased effect in the morning, nor do they specifically affect the respiratory system of the older adult. (Burchum & Rosenthal, 9 ed., pp. 92-93)

A client is going to begin external radiation therapy for his lung cancer. Which comment by the client would indicate to the nurse the need for additional teaching? 1. "I will shower with a mild soap and check my skin for areas of redness." 2. "I am looking forward to swimming laps again for my exercise." 3. "I am going to eat small meals and increase the protein and fiber in my diet." 4. "I will use only unscented emollient creams to the dry skin areas on my chest."

2 The client should avoid swimming during the treatment period because of the irritating chemicals in swimming pools. The other options—showering with a mild soap, eating small nutritious meals, and using an emollient cream—are correct for external radiation. (Lewis et al., 10 ed., p. 255)

The nurse receives report on assigned clients. One client is reported to be at the nadir for his cancer chemotherapy. How will this affect the nursing care plan? 1. Implement bleeding precautions. 2. Reinforce measures and teaching regarding preventing infections. 3. Anticipate nutritional problems caused by nausea and vomiting. 4. Assess for problems with fluid balance.

2 The nadir refers to the point in the chemotherapy when the leukocytes or neutrophils are at the lowest level. The client's ability to resist infections is at the lowest point, and the client is at the highest risk for developing an infection. Bleeding precautions are implemented with thrombocytopenia or decreased platelets. Nutritional problems are common throughout chemotherapy, and there is no increased risk for development of problems with fluid balance. (Lewis et al., 10 ed., pp. 250-254)

A client experiencing severe depression is admitted to the inpatient psychiatric unit. During the initial assessment, she says, "I feel like killing myself, but I wouldn't do that because of my kids." The nurse's priority action would be to: 1. Explore the reasons that the client might want to take her life. 2. Determine the severity of her suicidal risk. 3. Prevent the client from harming herself. 4. Guide her to consider alternative ways of coping.

2 The priority nursing action is to determine the suicidal lethality. Ask clients whether they plan to hurt themselves, what the method would be, and what factors might interfere with the rescue. The more detailed the plan, the more lethal and accessible the method. The more effort that is exerted to block rescue, the greater the likelihood will be of the suicidal effort being successful. Although the other three options are definitely plausible, they are not the priority. (Halter, 7 ed., pp. 485-486)

A client returns to the clinic to receive evaluation of his routine purified protein derivative (PPD) test for tuberculosis screening. The test result is positive. What is the best nursing interpretation of this information? 1. This is a serious type II reaction and could indicate that he has active tuberculosis; he will need further evaluation immediately. 2. The positive results indicate the client has been exposed to the tuberculosis bacilli and has had a delayed type IV response. 3. The client's immune system has been compromised, which allows the immune system to build up antibodies against the pathogen. 4. An autoimmune response has occurred, and the client will need further evaluation to determine appropriate treatment.

2 Type IV (cell-mediated, delayed hypersensitivity) reaction is a delayed response that occurs 24 to 72 hours after exposure to the allergen (e.g., PPD). The client has been sensitized to tuberculosis. There is no indication of active TB, and it is not a type II reaction. The client's immune system has not been compromised; rather, it has responded normally with the production of antibodies after exposure to the allergen. This does not represent an autoimmune response. (Lewis et al., 10 ed., pp. 199-200)

A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? 1. Use lemon-flavored glycerin swabs. 2. Apply antacid coating solutions and viscous lidocaine. 3. Brush oral plaques off with a soft toothbrush. 4. Have client swish mouth with a weak hydrogen peroxide solution.

2 Ulcerations in the mouth (stomatitis) can occur when a client is receiving chemotherapy medication. Alleviation of the pain can be achieved by administering systemic or local analgesics and coating agents such as antacids. Frequent saline rinses are encouraged. Lemon-glycerin swabs may irritate the mucosa and lead to further pain, as would trying to remove oral plaques. (Lewis et al., 10 ed., pp. 251-254)

What is a common side effect of radiation therapy that is not associated with the effect of radiation in the treatment field? 1. Reddened skin 2. Bone marrow suppression 3. Fatigue 4. GI disturbances

3 A general body or system effect is fatigue because it occurs as a result of changes in cell cycle patterns and toxic effects from cell destruction. The other problems (reddened skin, bone marrow suppression, GI disturbance) occur when radiation is directed at specific parts of the body. (Lewis et al., 10 ed., pp. 250-256)

A client with a diagnosis of schizophrenia repeatedly states, "There are flies eating my brain and making me feel weird." The client is most likely experiencing which of the following? 1. Ideas of reference 2. Grandiose delusions 3. Somatic delusions 4. Persecutory delusions

3 Bizarre ideas that focus on the body being incapacitated are known as somatic delusions and are sometimes observed in schizophrenia. Grandiose delusions are beliefs of being important. Ideas of reference or delusions of reference occur when a person believes or perceives that irrelevant, unrelated, or innocuous things in the world are referring to them directly or have special personal significance. Persecutory delusions are when a person believes (wrongly) that they are being picked on or threatened by someone/ something else. (Halter, 7 ed., p. 206)

A client asks the nurse why he has to take several chemotherapy agents at the same time. The nurse's response would be based on which principle? 1. The more medications that can be given together, the shorter the treatment period. 2. The cost is decreased because the medications are administered at the same time. 3. Multiple medications given together will attack the cancer cells at different levels. 4. One medication will interact with another to reduce incidence of side effects.

3 Combination drug therapy is important because different drugs inhibit cancer cell growth at various phases of cellular replication. This makes each of the medications more effective. Medications are given together because this is a more effective method of treatment, not because of cost or to reduce the side effects. (Lewis et al., 10 ed., p. 248)

A client has just received 250 mL of packed cells and is now receiving 1000 mL of D5W at 150 mL/hr. The client tells the nurse that he feels dizzy and has a headache. The nurse observes the distended jugular veins with the client in a semi-Fowler's position. What should be the nurse's initial response? 1. Notify the health care provider of the client's symptoms. 2. Check vital signs. 3. Reduce the D5W infusion to keep vein open rate. 4. Lay the client flat.

3 Headache and dizziness in a client receiving IV fluid are frequently signs of fluid overload from the increase in circulating volume, which increases cerebral vascular pressure. After decreasing the IV rate, the nurse should continue with the assessment of the vital signs. If other assessment findings (increased blood pressure, lethargy, bounding pulse, weight gain, adventitious breath sounds) confirm the problem, the physician needs to be notified. If the increase in circulating volume continues, it can cause pulmonary edema. (Lewis et al., 10 ed., p. 709)

The nurse is evaluating a central venous line before administering the client's chemotherapy. What observation would cause the nurse the most concern? 1. Nurse is unable to withdraw blood into line. 2. Dressing was changed 24 hours ago. 3. Inflammation and exudate are present at the insertion site. 4. Fluid infusing is D5W and 0.45% normal saline.

3 Irritation at the insertion site is a problem in a client who is immunocompromised. Checking the IV site and surrounding area for signs of infection is a priority nursing action. Frequently, central lines are long and narrow, and withdrawing blood may not occur. Transparent dressings are changed on an as-needed basis. Opaque (gauze) dressings are usually changed every 48 hours. (Lewis et al., 10 ed., pp. 295-297)

A client asks the nurse about an alternative remedy for hot flashes. Which dietary supplement is the client asking the nurse about? 1. Ginseng. 2. Valerian. 3. Feverfew. 4. Black cohosh.

3 Kava is an herbal supplement that is used to relieve anxiety, promote sleep, and relax muscles and is known to be hepatotoxic. Monitoring liver function studies would be an appropriate action. Ma huang (ephedra) is an herbal supplement that can cause hypertension and stimulates the central nervous system. (Burchum & Rosenthal, 9 ed., pp. 1328-1329)

The mother of a 15-month-old child who is immunosuppressed asks about continuation of the childhood vaccines. Which immunizationsare not recommended to be given to the childduring immunosuppression? 1. Diphtheria, tetanus, and pertussis (DTaP); hepatitis B 2. Haemophilus influenzae B 3. Varicella; measles-mumps-rubella (MMR) 4. Inactivated polio; diphtheria, tetanus, and pertussis (DTaP)

3 Live viruses are usually not administered when a client is immunosuppressed. Frequently, measles-mumps-rubella (MMR) vaccine and varicella vaccine are not given to the immunocompromised client; they may be administered when the client has a more competent immune system. Childhood vaccinations are encouraged when the client is not immunocompromised (in remission or not on immunosuppressant medications). (Hockenberry & Wilson, 9 ed., p. 1455)

The nurse is caring for a client with an acute onset of shortness of breath and a respiratory rate of 28 breaths per minute. Arterial blood gasses are pH 7.20; Paco2 47, HCO3 2 24. What is the priority plan of care? 1. Slow the respiratory rate with relaxation and sedation. 2. Improve the pH by administering sodium bicarbonate. 3. Determine a cause of the shortness of breath with further assessment. 4. Intubation to maintain respiratory effort.

3 Sudden shortness of breath with tachypnea is always a concern and a priority problem. The ABGs show that the client is in a respiratory acidosis that is uncompensated (from the sudden onset of symptoms). Further assessment should include a pulse oximetry reading, blood pressure, heart rate, auscultation of lungs, and assessment for tracheal shift and bilateral lung expansion. Anxiety level is another important assessment and should be addressed. Sedation would be contraindicated, since it would slow the respirator rate causing further retention of Paco2. Sodium bicarbonate is more commonly used in metabolic acidosis, and intubation is not warranted unless the client lacks a breathing response or more severe respiratory acidosis. (Lewis et al., 10 ed., pp. 288, 1616)

The nurse is caring for an older adult client with edema, tachycardia, hypertension, and jugular venous distention. Which nursing action should the nurse prioritize to evaluate the client's fluid status? 1. Measure the intake and output (I&O). 2. Check for thirst and skin turgor. 3. Evaluate changes in daily weight. 4. Evaluate vital signs every 4 hours.

3 The assessment findings demonstrate fluid volume excess. The priority assessment for a client with fluid problems is to obtain the daily weight. Weight gain and loss are the most accurate measurements of fluid gain and loss. Checking tissue turgor on an older adult is not accurate because many older adults have poor turgor. Thirst is too nonspecific and would be a proper assessment for dehydration rather than fluid volume excess. The I&O is important, but it is not as accurate in evaluating the amount of fluid retained as is the daily weight. (Lewis et al., 10 ed., p. 277)

The nurse prepares a liquid medication and then finds that the client no longer needs the medication. What is the most appropriate nursing action? 1. To keep the count correct, record that the dose was taken. 2. Charge for the dose because it must be paid for. 3. Record the medication as "not taken" and discard the poured dose. 4. Pour the medication back into the container.

3 The dose should be recorded as "not taken," and the poured dose should be discarded. If the dose is a controlled substance, the discarded dose must be witnessed. Checking the medication administration record or the medication order for changes before preparing the medication helps eliminate

What is the first step the nurse should take to ensure that the right medication is being given to a client? 1. Check the client's ID band. 2. Read the information insert for directions as to correct administration. 3. Check the order with the medication administration sheet. 4. Check the expiration date on the medication.

3 The first step in drug delivery to a client is to check the order with the medication administration sheet for possible discontinuance or a change in dose, route, or time. The question asks for steps to ensure the right medication is being given, not for client identification. (Potter & Perry, 9 ed., p. 635)

The nurse understands what major difference between benign and malignant tumors? Malignant tumors: 1. Are encapsulated and immovable 2. Grow at a faster rate than benign tumors do 3. Invade adjacent tissue and metastasize 4. Cause death, whereas benign tumors do not

3 The primary difference between benign and malignant tumors is the ability of the malignant tumor to invade adjacent tissues and metastasize. Benign tumors tend to be encapsulated, and both types of tumors can lead to death. As benign tumors expand, they can adversely affect organ function. The growth of malignant and nonmalignant tumors varies, depending on the characteristics and location of the tumor. (Lewis et al., 10 ed., p. 240)

Combined therapy of radiation and chemotherapy can have a significant therapeutic impact on the survival of an individual with cancer. The nursing priority for these clients includes measures to: 1. Monitor for acute renal tubular necrosis 2. Control nausea and vomiting 3. Prevent infection 4. Maintain hydration and nutrition

3 The statistics indicate that infection is the most common cause of morbidity in clients with cancer. Good handwashing, monitoring white blood cell counts, checking temperatures (watching for elevations), and providing protective isolation when needed (when clients are severely immunosuppressed) are the primary measures to prevent infection. (Lewis et al., 10 ed., p. 262)

The nurse is caring for a client who is being treated with chemotherapy for his lung cancer. The client has had two treatments in the last 2 days, and the nurse notes hyperkalemia and hyperuricemia on the latest serum laboratory values. The nurse understands that these are symptoms of: 1. Third-space syndrome 2. Syndrome of inappropriate antidiuretic hormone 3. Tumor lysis syndrome 4. Parathyroid deficiency

3 These two findings, hyperuricemia and hyperkalemia, are hallmark symptoms of tumor lysis syndrome, which often occurs at the onset of chemotherapy when a large number of tumor cells are destroyed. This process yields fatal biochemical changes of hyperkalemia, hyperuricemia, hypocalcemia, and hyperphosphatemia if not averted with adequate fluids. (Lewis et al., 10 ed., p. 263)

When preparing a client for electroconvulsive therapy (ECT), the nurse would include which of the following actions? 1. Provide orientation to time. 2. Assess vital signs for 30 minutes to 1 hour. 3. Remove dentures and maintain NPO status. 4. Encourage problem solving in social settings.

3 To prepare a client for ECT, the nurse must do the following: check the client's record for routine preoperative information; institute and maintain NPO status for 6 hours before the treatment because the client will be receiving a general anesthetic agent— short-acting barbiturate (methohexital) and muscle paralyzing agent (succinylcholine); have the client remove dentures; and administer preoperative medication. (Halter, 7 ed., p. 271)

The nurse understands that the following are general adverse effects of antineoplastic drugs. Select all that apply. 1. Urinary retention 2. Infertility 3. Stomatitis 4. Bone marrow depression 5. Extravasation 6. Nausea

3, 4, 6 Adverse effects of antineoplastic drugs can be classified as acute, delayed, or chronic. Acute toxicity includes nausea, vomiting, arrhythmias, and allergic reactions. Delayed side effects include stomatitis, alopecia, and bone marrow depression. Chronic toxicity involves organ damage. Common urinary problems include cystitis and nephrotoxicity. Extravasation is not an adverse effect but a complication of an infiltrated IV running a chemotherapy medication that is a vesicant. (Lewis et al, 10 ed., pp. 250-256)

A nurse case worker suspects older adult neglect. Which assessment findings during a home visit would confirm this? (Select all that apply.) 1. Confusion and disorientation 2. Recent hip fracture 3. Poor nutrition and hygiene 4. Dirty dishes in the sink 5. Outdated prescription bottles 6. Missing hearing aids

3, 5, 6 Lack of assistive devices, medication mismanagement, and access to basic physiologic needs such as hygienic care, food, and water are characteristics of neglect in the older adult. A hip fracture is typically caused by osteoporosis in older adults, not neglect. Confusion and disorientation are signs of dementia. Dirty dishes in the sink is not a sign of neglect. (Halter, 7 ed., p. 540)

The nurse is admitting a client from the post anesthesia care unit. Postoperative prescriptions include D5 1⁄2 NS with 40 mEq/L of KCl @ 100 mL/hr. The current liter of lactated Ringer's solution has 450 mL left in the bag. What should the nurse's next action be? 1. Finish the current liter of fluid at 100mL/hr. 2. Assess urine output. 3. Change the solution to D5 1⁄2 NS with 40 mEq/L KCl at 100 mL/hr. 4. Assess the IV site.

4 Although the cost-effective decision is to finish the current liter of fluid, at the prescribed rate it will take 4 hours to infuse. Because there is a loss of potassium from urinary and GI loss with surgery, it is important to begin potassium replacement upon arrival to the unit. The initial assessment of the IV site should take place prior to the infusion of potassium. Determination of kidney function and urine output is also important to establish prior to the infusion of potassium, but IV assessment is a higher priority, since it can cause injury to the client if an infiltration is present. (Lewis, et al., 10 ed., p. 282)

A client asks the nurse about an alternative remedy for hot flashes. Which dietary supplement is the client asking the nurse about? 1. Ginseng. 2. Valerian. 3. Feverfew. 4. Black cohosh.

4 Black cohosh is an herbal supplement used for treating symptoms of menopause, including hot flashes, vaginal dryness, palpitations, depression, irritability, and sleep disturbance. The nurse should determine whether the client's symptoms are caused by tamoxifen and other selective estrogen receptor modulators, if this is the situation, then black cohosh should not be used. Ginseng improves mood, boosts endurance, and may lower blood glucose. Feverfew is taken for migraine prophylaxis. Valerian has sedative properties that promote sleep and reduce anxiety. Burchum & Rosenthal, 9 ed., pp. 1321-1328)

A client is worried he may have been exposed to AIDS. What will be important for the nurse to explain to this client? 1. Symptoms of AIDS will develop immediately in sexually active individuals. 2. Clients may remain asymptomatic for an indefinite period of time. 3. Symptoms of AIDS are usually seen before the client is found to be HIV-positive. 4. After exposure to the virus, symptoms may develop within 6 to 12 weeks or as late as 6 months.

4 Clients usually have symptoms within 6 to 12 weeks of exposure, but symptoms may not develop until 6 months after exposure. This is the period of seroconversion. The symptoms do not develop immediately in sexually active individuals. The client may remain asymptomatic for an undetermined period of time. The client may be HIV positive for years before he is diagnosed as having AIDS. (Lewis et al., 10 ed., p. 220)

The nurse is admitting a 5-month-old infant. The health care provider has ordered an IV solution of normal saline. There is also an order for potassium chloride (KCl) to be added to the solution. The infant's temperature is 101°F (38.8°C) rectally, and the pulse is 120 beats/min; the infant is irritable and has not voided. What is the priority nursing action? 1. Wait for 1 hour from admission time and then begin the infusion of normal saline with the KCl. 2. Feed the infant before adding the KCl to the infusing solution. 3. Consider the order a stat order and begin the infusion immediately. 4. Start the normal saline infusion and hold the KCl until adequate urinary output has been documented.

4 In infants (and adults), validation of renal function must be established before the delivery of IV KCl. This is necessary to prevent hyperkalemia and possible death. The key point in the question is that the infant has not voided, so the prudent nurse should hold the KCl until adequate urine output is documented. (Lewis et al., 10 ed., p. 277)

What are the nursing interventions regarding care of a client with a vaginal radium implant? 1. Clamp and drain the urinary retention catheter. 2. Provide a high-residue diet. 3. Place the client in a semiprivate room. 4. Raise the head of the bed no more than 20 degrees.

4 Once the implant is in place, keeping it in the exact measured position without disruption is a primary goal of care. Strict bed rest is maintained. The head of the bed should be raised only slightly to accomplish this. A urinary retention catheter is placed for gravity drainage. The client should be in a private room. Constipation should be avoided, but a high-residue diet will increase the bulk of the stool and possibly dislodge the implant. (Lewis et al., 10 ed., p. 250)

A client with a diagnosis of AIDS has developed P. jiroveci pneumonia (PJP, PCP). What will be important for the nurse to include in the nursing care plan? 1. Put a mask on the client whenever he has visitors in his room. 2. Explain to the client why he cannot go outside his room. 3. Wear a mask and gown when providing direct care to the client. 4. Wear a gown and gloves when assisting the client with personal hygiene.

4 P. jiroveci pneumonia (PJP, PCP) is not easily transmitted from an infected person to a healthy person. The pathogen is frequently dormant in the body and is reactivated when the client's immune system is significantly depressed. There is no need for airborne or droplet precautions, but standard precautions must be strictly adhered to with this client. (Lewis et al,. 10 ed., p. 222)

A client has systemic lupus erythematosus (SLE). What statement best describes this client's immune response? 1. A delayed hypersensitivity that is cell mediated 2. An immediate reaction to prior exposure 3. An immune complex that forms with antibody production 4. An immune response that no longer recognizes normal body Tissue

4 SLE is characterized as an autoimmune disorder in which the body begins to invade and destroy normal tissue. A delayed hypersensitivity is a type IV response that is characteristic of a transplant rejection or reaction to tuberculin skin testing. An immediate reaction describes a type I reaction characterized by a prior exposure to antigen. This occurs with atopic reactions and anaphylaxis. An immune complex that forms with antibody production is a type III response, which occurs with acute glomerulonephritis. (Lewis et al., 10 ed., pp. 197-200)

The nurse is reviewing with a certified nursing assistant (CNA) the care for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS) and has developed P. jiroveci pneumonia (PJP, PCP). Which of the following precautions would the nurse review with the CNA? 1. Strict handwashing 2. Airborne precautions 3. Contact precautions 4. Standard precautions

4 The CDC recommends standard precautions for all clients; this is particularly important for the client with AIDS. Although strict handwashing is not an incorrect response, this should be performed when caring for all clients and is a part of standard precautions. Airborne precautions are not indicated for clients with opportunistic infections such as P. jiroveci pneumonia (PJP, PCP). Protective isolation is indicated for clients who are severely immunocompromised (e.g., clients who have undergone transplants). (Lewis et al., 10 ed., p. 218)

A client is being seen in the emergency department after an accident. He has no obvious physical injuries, and his blood pressure is 158/90 mmHg. He is crying loudly, wringing his hands, and pacing the floor. His respiratory rate is 32 breaths/ min, and he says he feels lightheaded. What is the best nursing response? 1. Have him lie down and begin O2 per nasal cannula at 4 L/min. 2. Put him on a stretcher and begin a head-to-toe assessment. 3. Perform a quick neurologic examination to determine his level of orientation. 4. Have him sit down and help him breathe into a paper sack.

4 The client is experiencing acute respiratory alkalosis from hyperventilation caused by anxiety. Rebreathing in a paper sack will help reestablish normal Paco2 levels. The other options do not address the origin of the problem and may further increase his anxiety. (Potter, 9 ed., p. 944)

The client is receiving an IV of 0.9% NaCl at 125 mL/hr. The client had a colon resection this morning. He has a nasogastric tube to suction and an ileostomy, and he is becoming increasingly restless. The nurse reviews the serum laboratory values. Which value should the nurse consider a priority? 1. Blood urea nitrogen 28 mg/dL (10 mmol/L). 2. Serum glucose 155 mg/dL (8.6 mmol/L). 3. Hemoglobin 13.5 mmol/L, hematocrit 41% (0.41). 4. Sodium 155 mEq/L (mmol/L).

4 The client is losing fluids, but the replacement fluid only contains sodium. The laboratory value of 155 mEq/L (mmol/L) of sodium indicates that the client has hypernatremia. This increases retention of fluids and subsequently increases the cardiac workload. The glucose level is elevated, but that is not unusual in clients in the immediate postoperative period. The hemoglobin and hematocrit values are within the normal ranges. The blood urea nitrogen (BUN) level is elevated, and this needs to be investigated and correlated with the serum creatinine level. However, it is not alarmingly high and could be an indication of decreased fluids, and it is not the priority concern. (Lewis et al., 10 ed., p. 292)

The nurse is verifying whether to give a medication to a client. What would be the first nursing action? 1. Check the client's name and hospital number. 2. Validate the expiration date of the drug. 3. Determine the appropriate route of delivery. 4. Review the orders on the medication administration record.

4 The medication administration record should be reviewed for current physician's orders. Medication administration records are routinely reviewed to determine the currency of medication orders. The client's name and hospital number are checked to validate client identification before administration of the medication. The nurse should check the medication for the expiration date when she prepares the medication, and the physician will order the route of administration. (Potter & Perry, 9 ed., p. 626.)

The nurse is admitting a client with type 1 diabetes. What values on the arterial blood gases would indicate the client is developing a complication because of his poorly controlled diabetes? 1. Paco2 48 mmHg, pH 7.34, Pao2 98 mmHg, HCO3 24 mEq/L (mmol/L). 2. Paco2 33 mmHg, pH 7.48, Pao2 88 mmHg, HCO3 26 mEq/L (mmol/L). 3. Paco2 40 mmHg, pH 7.45, HCO3 32 mEq/L (mmol/L), O2 saturation 90%. 4. Paco2 38 mmHg, pH 7.31, HCO3 20 mEq/L (mmol/L), base excess 22.

4 This series of values (Paco2 38 mmHg, pH 7.31, HCO3 20 mEq/L [mmol/L], base excess 22) best represents metabolic acidosis, a complication of type 1 diabetes, which is the correct answer. This series of values (Paco2 48 mmHg, pH 7.34, Pao2 98 mmHg, HCO3 24 mEq/L [mmol/L]) reflects respiratory acidosis; notice the elevated Paco2 and decreased pH. This series of values (Paco2 33 mmHg, pH 7.48, Pao2 88 mmHg, HCO3 26 mEq/L [mmol/L]) reflects respiratory alkalosis; notice the decreased Paco2 and increased pH. This series of values (Paco2 40 mmHg, pH 7.45, HCO3 32 mEq/L [mmol/L], O2 saturation 90%) reflects metabolic alkalosis; notice the elevated Bicarbonate and pH. (Lewis et al., 10 ed., p. 289)

A client is experiencing a lack of logical thought progression, resulting in disorganized and chaotic thinking. The nurse understands this to be: 1. Delusions of grandeur 2. Ideas of reference 3. Depersonalization 4. Associative looseness

4 According to Eugen Bleuler's classic symptoms of schizophrenia, associative looseness is a lack of logical thought progression resulting in disorganized and chaotic thinking. Grandiose delusions are beliefs of being important. Ideas of reference or delusions of reference occur when a person believes or perceives that irrelevant, unrelated, or innocuous things in the world are referring to him or her directly or have special personal significance. Depersonalization is characterized by a change in how an affected individual perceives or experiences his or her sense of self. The usual sense of one's own reality is temporarily lost or changed. A feeling of detachment from, or being an outside observer of, one's mental processes or body occurs such as the sensation of being in a dream. (Halter, 7 ed., p. 213)

An infant has an active acquired immunity. Which statement best explains this type of immunity? 1. The infant has received immunizations. 2. Immunity was transferred from the mother to the infant. 3. The infant is recovering from a childhood disease that conferred immunity. 4. The infant has received gamma globulin after exposure to hepatitis.

1 Active acquired immunity occurs when a client (infant, child, or adult) receives an immunization against a specific disease. Natural active immunity occurs when the client has had the disease. Natural passive immunity occurs with transfer of antibodies from the mother to the infant at birth or through breast milk. Passive artificial immunity occurs with injection of gamma globulins; the response is immediate but short term. (Lewis et al., 10 ed., p. 192)

A client is receiving IV antibiotic therapy. The order is for methicillin 750 mg IV. The nurse has a vial on hand that contains 1 gm. The instructions for reconstitution say to add 1.5 mL sterile water. Reconstituted solution will contain 500 mg methicillin per milliliter. How much will the nurse give? Answer: __________ mL

1.5 mL The dosage calculation cannot be made from the amount of solution added to the vial. The ratio of mg per mL after reconstitution is 500 mg/mL. (Potter & Perry, 9 ed., pp. 618-620)

The nurse is updating a teaching plan for a client who has cancer and has been taking doxorubicin for the past several months. What is important to review with the client? 1. Report symptoms of hematuria. 2. Increase intake of oral fluids. 3. Avoid folic acid intake. 4. Report symptoms of dyspnea.

4 One of the most common and most severe toxicities of doxorubicin is cardiotoxicity. After months of treatment, this can manifest as heart failure (dyspnea, tachycardia, peripheral edema). Early side effects include dysrhythmias and electrocardiogram (ECG) changes. These can occur within hours of receiving the medication. (Lewis et al., 10 ed., p. 256)

A client has returned to the room from the postoperative recovery area. He is lethargic but responsive. He has O2 via nasal cannula at 4 L/min and an IV infusing at 125 mL/hr. On the initial nursing assessment, the nurse notes that the O2 saturation is 82%. What is the priority nursing action? 1. Perform a complete neurologic check. 2. Increase the O2 flow and recheck the pulse oximetry. 3. Suction the client and recheck the vital signs. 4. Stimulate the client to cough and deep breathe.

4 The client is lethargic from the anesthetic and needs to be stimulated to deep breathe to facilitate ventilation. The client is at increased risk for development of respiratory acidosis and hypoxemia. Stimulation should be done before suctioning to determine whether it relieves the problem. Increasing the oxygen flow does not address the problem of hypoventilation. Neurologic checks can be done but are not a priority at this time. (Lewis et al., 10 ed., p. 288)