NCLEX 12
An anxious parent of a 4 year-old consults the nurse for guidance on how to answer the child's question: "Where do babies come from?" What is the nurse's best response to the parent? "Full and detailed answers should be given to any questions." "Children ask many questions, but are not looking for answers." "This question indicates interest in sex beyond this age." "When a child asks a question, give a simple answer."
"When a child asks a question, give a simple answer." During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask one question, they are looking for one answer. When they are ready, they will ask for more detailed information.
The client is one day post-op following a colon resection and there is an order to assist the client to walk in the hallway at least three times while awake. When the nurse delegates this task to the unlicensed assistive personnel (UAP), which instruction by the nurse is most appropriate? "Apply a gait belt around the client's waist if the client reports feeling dizzy." "Allow the client to sit on the side of the bed before assisting the client to stand and walk." "When assisting the client, be sure to ask about the intensity of the pain." "Have the client stand for at least two minutes before starting to walk."
"Allow the client to sit on the side of the bed before assisting the client to stand and walk."
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be an initial action by the nurse? Discuss the appropriate use of "time-out" Explain that the child needs extra attention Explain that this behavior is expected Arrange to change client care assignments
Explain that this behavior is expected During normal development, fear of strangers becomes prominent and begins around age 6 to 8 months-old. Such behaviors include clinging to parent, crying and turning away from the stranger. These fears and behaviors extend into the toddler period. In the toddler period, separation anxiety is at its peak. As the child ages the behavior has a tendency to wane.
A health care provider has written, "Morphine sulfate 2 mg IV every three to four hours as needed for pain" on the chart of a child weighing 22 pounds (10 kg). What should be the nurse's action? Hold the medication and contact the health care provider Check with the pharmacist Administer the prescribed dose as ordered Give the dose every six to eight hours
Hold the medication and contact the health care provider The usual pediatric dose of morphine is 0.1 mg/kg every three to four hours. At 10 kg, this child typically should receive 1 mg every three to four hours.
The nurse is admitting a 72 year-old with a diagnosis of right-sided heart failure. What finding should the nurse anticipate when assessing the client? Bibasilar crackles Decreased urine output Jugular vein distention Pleural effusion
Jugular vein distention Signs of right-sided heart failure include jugular vein distention at 35 to 45 degrees or higher elevation of the head of the bed, fatigue, nausea, vomiting, sacral edema and bilateral feet and/or ankle edema.
A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki disease and treatment involving immunoglobulins. The nurse should recognize which scheduled immunizations will be delayed? Inactivated polio vaccine (IPV) Mumps, measles, rubella (MMR) Haemophilus Influenzae Type b (Hib) Diptheria, tetanus, pertussis (DTaP)
Mumps, measles, rubella (MMR) Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to possible interference with the body's ability to form antibodies.
A nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is an appropriate action for the nurse to take? Disconnect the client from the ventilator and use a manual resuscitation bag Perform a quick assessment of the client's overall condition along with respiratory effort Call the respiratory therapist for help to troubleshoot the alarm Press the alarm re-set button on the ventilator and observe the client
Perform a quick assessment of the client's overall condition along with respiratory effort A number of situations can cause the high-pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? Four years One year Three years Two years
Two years A child should be at least 2 years old to use the radial pulse to assess heart rate.
A client is scheduled to have a blood test for cholesterol and triglycerides the next day. What statement should the nurse include in the directions for the client? "Stay at the laboratory so two blood samples can be drawn an hour apart." "Be sure and eat a fat-free diet until the test." "Have the blood drawn within two hours of eating breakfast." "Do not eat or drink anything but water for 12 hours before the test."
"Do not eat or drink anything but water for 12 hours before the test." Serum lipid levels should be obtained from clients who have been fasting for at least 12 hours.
A client who had surgery is discharged on warfarin (Coumadin). Which statement by the client is incorrect and indicates a need for further teaching? "I know I must avoid crowds." "I will keep all laboratory appointments." "I will report any bruises or unusual bleeding." "I plan on using an electric razor for shaving."
"I know I must avoid crowds." There are no specific reasons for the client on warfarin to avoid crowds. Clients should not use a straight edge razor, should report any unusual bleeding and must keep all laboratory appointments when taking the blood thinner warfarin.
The nurse is teaching a group of clients about skin cancer. Which client statement indicates the need for further education about reducing the risk of skin cancer? "I wear sunglasses with ultraviolet protective lenses." "I only tan in the controlled setting of a tanning booth." "I found a sunscreen with a sun protective factor of 30." "I make sure to come inside between noon and 2 pm."
"I only tan in the controlled setting of a tanning booth." Tanning booths and sun lamps are no safer than the natural sun in terms of cellular damage and potential for developing skin cancer. The other self-help measures have positive effects on reducing the chance of damage from ultraviolet rays.
The nurse is assessing a client in the emergency department. Which statement suggests that the client is experiencing acute cardiac ischemia? "As I take a deep breath the pain gets worse." "The pain is right here in my stomach area." "When I sit up the pain gets worse." "I've got a pressure deep in my chest behind my breast bone."
"I've got a pressure deep in my chest behind my breast bone." Pain that gets worse with deep breaths may be related to a disorder of the lungs. Pain that gets worse with movement is probably from the muscles or bones in the chest, but is not cardiac ischemia. Pain that worsens in the supine position and is relieved with sitting up is characteristic of pericarditis. Although pain in the stomach, especially after a meal, may actually be angina, a person most typically will feel pain, aching or pressure in the middle of the chest, just beneath the sternum. Many people describe the sensation as discomfort or heaviness instead of pain, so the term discomfort should be used when asking clients about their findings.
A client tells a nurse: "I have decided to stop taking sertraline (Zoloft) because I don't like the nightmares, sex dreams and obsessions I have had since starting on the medication." What is an appropriate response by the nurse? "This medication should be continued despite unpleasant symptoms." "Many medications have potential side effects." "Side effects and benefits should be discussed with your health care provider." "It is unsafe to abruptly stop taking any prescribed medication."
"It is unsafe to abruptly stop taking any prescribed medication." Abrupt withdrawal the short-acting SSRI sertraline (Zoloft) causes SSRI Discontinuation Syndrome. A slow tapering of the medication will be prescribed to avoid the symptoms associated with this syndrome, which may include insomnia, headache, dry mouth, nausea and diarrhea.
A child is admitted to the hospital with findings consistent with rheumatic fever. During the admission process, which statement made by a parent would the nurse associate with this disease? "Our child is being tested for allergies and has reacted to some allergens." "Last week both feet had a fungal skin infection." "Our child had a sore throat a month ago, which I treated with an herbal remedy." "Both ears were infected when our child was 3 months-old."
"Our child had a sore throat a month ago, which I treated with an herbal remedy." Evidence supports a strong relationship between group A streptococcal infections and subsequent rheumatic fever (usually within two to six weeks). Therefore, the history of sore throat may have been an undiagnosed strep A infection. Appropriate antibiotic treatment of strep throat is the most effective way to reduce the risk of developing rheumatic fever.
A nurse is giving instructions to the parents of a newborn infant with oral candidiasis. Which statement made by a parent is incorrect and indicates a need for more teaching? "The therapy can be discontinued when the spots disappear." "I will boil the nipples and pacifiers for 20 minutes." "I will use a dropper to place the medicine on each side of my baby's mouth." "Nystatin should be given four times a day after my baby eats."
"The therapy can be discontinued when the spots disappear." The therapy should be continued for a week, even if lesions have disappeared within a few days. If the mother is breast-feeding, mother and baby should be treated at the same time to prevent re-infection.
A 3 year-old child has findings that may suggest a neuroblastoma. While listening to the concerns of the parents, which finding is consistent with this diagnosis and requires follow-up by the health care provider? "Our child has been quieter than normal lately and has lost weight." "He doesn't seem to be going to the bathroom as much and his urine is dark yellow in color." "We keep having to buy him larger size pants because he's growing so big around the waist." "He seems to be getting weaker and weaker and is sometimes unsteady on his feet."
"We keep having to buy him larger size pants because he's growing so big around the waist." One of the most common signs of neuroblastoma is increased abdominal girth due to the mass or tumor in the abdomen. The mass can cause pain and/or a feeling of fullness and the pressure may affect the child's bladder or bowel. Although the child with a neuroblastoma may not want to eat (which can lead to weight loss), this finding could have many causes. A more significant finding would be if the parents reported that child keeps outgrowing clothing or that clothing is tight around the abdomen.
The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? Administering two antituberculosis drugs Aminoglycoside antibiotics High doses of B complex vitamins An anti-inflammatory agent
Administering two antituberculosis drugs In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different antitubercule medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid.
A woman diagnosed with bipolar disorder is to take lithium (Eskalith, Lithobid) as part of her treatment. What should the nurse discuss with the client as part of the teaching plan? Risk of concomitant use of oral contraceptives Weight reduction Alcohol abstinence Smoking cessation
Alcohol abstinence Alcohol potentiates the effects of lithium, resulting in central nervous system depression and impairment of judgment, thinking and psychomotor skills. The client should be cautioned to avoid drinking alcoholic beverages.
A nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? Widening pulse pressure Bradycardia Distended neck veins Pleural friction rub
Distended neck veins In cardiac tamponade, intrapericardial pressures prevent adequate filling of the heart from the vena cava, and reduce cardiac output. As a result, venous pressures rise and the neck veins become distended.
A nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which activity would be an appropriate diversional activity? Play hand-held games Kick balloons with right leg Play "Simon Says" Throw bean bags
Play hand-held games Immobilization with traction must be maintained until bone ends are in satisfactory alignment and with adequate regrowth of the bone. Activities that increase mobility interfere with the goals of treatment.
A nurse is assigned to an adolescent unit. Which of these groups of needs would the nurse expect to have to deal with that day? School performance, reading, journal writing Privacy, autonomy, peer interactions Independence, confidence, narcissism Interest in sports, competition, being right
Privacy, autonomy, peer interactions Adolescents display the need for privacy, autonomy and peer interaction concurrent with an evolving sense of identity.
A nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which instruction is appropriate for the nurse to include during discharge teaching with the parents? Report a persistent cough to the health care provider within 24 hours The child may gargle with saline as necessary for discomfort Administer chewable aspirin for pain around the clock every six hours The child can return to school after being home for four days
Report a persistent cough to the health care provider within 24 hours Persistent coughing should be reported to the health care provider as this may indicate bleeding by a trickling of blood into the back of the throat. The other items are incorrect information especially the aspirin, which is not to be given to children. The saline may irritate the wound where the tonsils were removed.
The nurse observes a coworker removing a narcotic from the electronic medication dispensing machine and self-medicating. Which action is required for the nurse who observes this behavior? Schedule an intervention to confront the coworker Encourage the coworker to talk to someone about getting help Ask other staff members if they have observed the coworker diverting drugs Report the coworker to the nursing supervisor
Report the coworker to the nursing supervisor Nurses who divert drugs pose a threat to client safety and are a legal liability for the facility, which is why the behavior must first be reported to the unit manage or other nursing supervisor. The nurse practice act in some states also mandate reporting unsafe nursing practice to the board of nursing. Drug diversion is often a symptom of substance use disorder but the coworker may not necessarily be an addict. An intervention may be scheduled after specific examples of destructive behaviors are collected (from other staff and medication audits) and the coworker is confronted with the evidence.
A nurse admits a client with hypertension who reports experiencing dizziness after taking diltiazem (Cardizem, Cartia, Dilacor, Diltia, Taztia, Tiazac). Which focus is important for the nurse to assess? Activity and rest patterns Daily intake of potassium Appearance of feet and ankles Schedule for taking medication
Schedule for taking medication A critical focus is whether the client has complied with the prescribed medication schedule and dose. Although diltiazem can be taken either in the morning or evening, taking the medication in the evening might help with this common side effect.
The client is scheduled for electroconvulsive therapy (ECT) in the morning. Which intervention must be completed prior to having this procedure? Pre-anesthesia lab work Electroencephalogram (EEG) Blood type and crossmatch Signed informed consent
Signed informed consent Modern ECT is administered under general anesthesia. An electroencephalogram (EEG) is connected during the procedure but is not usually ordered pre-operatively. There's no need for a type and crossmatch. A basic metabolic panel (BMP) and complete blood count (CBC), as well as some other labs, may be ordered, as well as a ECG. But most importantly, the client has the right to be fully informed about the treatment and give written consent for the procedure.
A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include which approach? A steep rise in provider fees and in insurance premiums High costs of diagnostic and end-of-life treatment procedures Increased numbers of older adults and of the chronically ill of all ages The escalation of fees with a decreased reimbursement percentage
The escalation of fees with a decreased reimbursement percentage The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee-for-service. Reimbursement for Medicare and Medicaid recipients based on fee-for-service also escalates health care costs.
A nurse states, "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of which concept? Prejudice Discrimination Stereotyping Racism
Stereotyping Stereotyping refers to defining people and institutions, mentally or by attitudes, with narrow, fixed traits, rigid patterns, or with inflexible "boxlike" profile characteristics. Stereotyping is one of the common concerns of nurses when they begin to study different cultures and learn about transcultural nursing. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. Discrimination is the unfair treatment of a person or group on the basis of prejudice. Racism is the belief that race is the primary determinant of human traits and capacities and that racial difference produces an inherent superiority of a particular race.
A nurse is caring for a client who is receiving a blood transfusion and develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? Take vital signs and observe for further deterioration Administer Benadryl and continue the infusion Slow the rate of infusion Stop the infusion
Stop the infusion This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion by disconnecting at the IV insertion site. The nurse should then start a saline line at the IV insertion site and notify the health care provider.
A nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis B? The number of persons in a population who develop hepatitis B during a specific period of time The percentage of deaths resulting from hepatitis B during a specific time The total number of persons in a population who have hepatitis B at a particular time The occurrence of hepatitis B in the population at a particular time
The number of persons in a population who develop hepatitis B during a specific period of time This is the correct definition of incidence of a disease.
A nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? Reprimand the child and give a 15-minute "time out" Assert authority over the child through limit setting Maintain a permissive attitude for this behavior Use patience and a sense of humor to deal with this behavior
Use patience and a sense of humor to deal with this behavior The nurse should help the parents see that negativity is a normal part of growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.
After placement of a ventriculoperitoneal (VP) shunt as a treatment for hydrocephalus of their infant, the parents ask a nurse: "Why is there a small incision in the abdomen?" Which response would be the best for explaining the purpose of the incision? "It's used to visualize the abdominal organs for correct catheter placement." "It's used to pass the catheter into the abdominal cavity." "That's what is used for insertion of the catheter into the stomach." "It's there so the tubing can be inserted into the urinary bladder."
"It's used to pass the catheter into the abdominal cavity." The preferred procedure in the surgical treatment of hydrocephalus is the placement of a ventriculoperitoneal shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, which is commonly the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt tip can be guided into the peritoneal cavity.
The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? An ICU nurse and intensivist remotely monitor ICU clients around the clock An ICU nurse is on-call to answer questions when needed Less staff is needed on site when a remote eICU is available Clients can ask the intensivist for a second opinion
An ICU nurse and intensivist remotely monitor ICU clients around the clock Using cameras, microphones, and high-speed computer data lines, the eICU involves having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote locations around the clock. The eICU does not change the ratio of nurses to clients at the bedside, but it does make the nurse's bedside time more productive and assistance from their remote colleagues is only a push button away.
The client has just had an enteral feeding tube inserted. What would be the most accurate method to verify initial placement of the feeding tube? Abdominal x-ray Auscultation with air insertion Aspiration for gastric contents Flushing tube with saline
Abdominal x-ray The most objective and recommended approach to confirm correct tube placement after initial placement is radiography. This will determine if the tube is in the duodenum or jejunum and not in the airways of the lungs. After initial placement has been confirmed, the nurse can then verify placement by checking the pH of the aspirated gastric contents. Aspirates of pH 5.5 or below will indicate correct placement in most clients. The "whoosh" test is no longer recommended and should not be used.
A client, admitted with palpitations and dyspnea, is diagnosed with atrial fibrillation (AF). Normal sinus rhythm is later restored using pharmacologic interventions. In addition to controlling cardiac rate and rhythm, the nurse understands that treatment for AF must include which of the following approaches? Catheter ablation Anticoagulation Cardioversion Coronary artery bypass surgery
Anticoagulation In addition to rate and rhythm control, acute management of AF includes anticoagulation. Effective anticoagulation in clients with AF significantly reduces the risk of stroke and other thromboembolic events. When a client does not respond to pharmacologic interventions to restore sinus rhythm, cardioversion is used. Catheter ablation is used to disconnect the triggers for AF, but is not the first line of treatment. CABG is not used to treat AF.
The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.) Capillary refill 6 seconds on the affected toes Trace amount of serosanguineous drainage on the groin dressing Pale color of the affected limb Bruising or lump at the insertion site Nonpalpable pedal pulse on the affected limb
Capillary refill 6 seconds on the affected toes Pale color of the affected limb Nonpalpable pedal pulse on the affected limb A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds.
A nurse is teaching parents of an infant about the introduction of solid food to their baby. What is the first food that the nurse should teach the parents to add? Fruit Vegetables Meats Cereal
Cereal Cereal is usually introduced first because it is well-tolerated, easy to digest and fortified with iron. Then the meats or vegetables are introduced. The fruit is sweeter and often is recommended to be introduced last because of this; infants often like fruit the best.
The RN is responsible for a client in isolation. Which task can be delegated to a practical nurse (PN)? Observation of the client's total environment for risks of harm Assessment of the client's attitude about infection control Reinforcement of isolation precautions with visitors Evaluation of staff compliance with infection control measures
Reinforcement of isolation precautions with visitors PNs and UAPs can reinforce information that was originally given by the RN. The other options are responsibilites of the RN and cannot be delegated.
A school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response by the nurse should be to do what with the tooth? Place the tooth in a clean plastic bag for transport to the dentist Rinse the tooth in water before placing it into its socket Ask the child to replace the tooth even if the bleeding continues Hold the tooth by the roots until reaching the emergency room
Rinse the tooth in water before placing it into its socket Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth into its socket within 30 minutes while avoiding contact with the root. The child should be taken to the dentist as soon as possible.
There are new orders for the client's intravenous solution: "Decrease IV rate to 50 mL/hr and discontinue when infusion is complete." There is 250 mL remaining in the current 500 mL bag. The time is 10:30 am (1030 in military time). At what time will the infusion be complete? State the answer in military time.
Solving with ratio proportion: 50 mL/1 hr = 250 mL/x hr x= 5 hr and 1030 + 5 = 1530. Or solving with logic: 250 mL remain/50 mL = 5 hours left 1030 (10:30 am) + 5 more hours = 1530 (using the 24-hour clock, or 3:30 pm)
The nurse is teaching the parents of a child with sickle cell disease about ways to prevent complications and crises. What information would be a priority for the nurse to emphasize to the family? The child may not be able to follow routine immunization schedules The child should be cautious of being exposed to people with a cold or fever The child should avoid becoming overheated or dehydrated during physical activity and exercise The child can maintain normal activity with some restrictions
The child should avoid becoming overheated or dehydrated during physical activity and exercise The goal of sickle cell treatment is to manage and control symptoms and to prevent sickle cell crisis. Fluid loss caused by overheating and dehydration can trigger a sickle cell crisis. People with sickle cell anemia need to keep their immunizations up-to-date, treat infections quickly, and avoid too much sun exposure.
The oncology client reports pain, and the provider orders hydromorphone (Dilaudid, Exalgo) IM 0.015 mg/kg right away. How many milligrams does the nurse administer? The nurse checks the chart and determines the client weighs 150 pounds. How many milligrams of hydromorphone (Dilaudid, Exalgo) will the nurse administer? (Round to the nearest hundredth and write only the number.)___________mg.
Using dimensional analysis, the final units will be milligrams, so begin the equation with milligrams on top, then multiply to cancel unwanted units until only the milligrams remain. (0.015 mg/kg) X (1 kg/2.2 lbs) X (150 lb/1) = 2.25/2.2 = 1.0227 = 1.02
A 52 year-old postmenopausal woman asks the nurse how frequently she should have a mammogram. How should the nurse respond? "Yearly mammograms are advised for any women over 35." "Once a woman reaches 50, she should have a mammogram yearly." "Your health care provider will advise you about your risks and the frequency." "Unless you had previous problems, every two years is best."
"Once a woman reaches 50, she should have a mammogram yearly." The American Cancer Society recommends a screening mammogram by age 40, every one to two years for women 40 to 49, and every year from age 50 onward. If there are family or personal health risks, other more frequent and additional assessments may be recommended.
The client is diagnosed with infective endocarditis and is receiving antibiotic therapy. Which finding suggests that the antibiotic therapy has not been effective and must be reported to the health care provider immediately? Temperature of 103 F (39.5 C) Nausea with vomiting Muscle tenderness Diffuse macular rash
Temperature of 103 F (39.5 C) Persistent, prolonged fever over 72 hours after the initiation of antibiotic therapy may be an indication that the antibiotics are not effective and may need to be changed to a different medication.
The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother is incorrect and indicates the need for further teaching? "I dip the pacifier in honey so it is better taken." "I'm going to try feeding my baby some rice cereal this week." "I keep formula made up ahead of time in the refrigerator for 24 hours." "When the baby wakes at night for a bottle, I give a feeding."
"I dip the pacifier in honey so it is better taken." The use of honey has been associated with infant botulism and should be avoided until after one year of age. Botulism effects the nervous system and often results in permanent damage. Older children and adults have digestive enzymes that kill the botulism spores.
The nurse is teaching a Lamaze class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? "I may experience postpartum depression up to a year after delivery." "It's common for women with postpartum depression to have delusions about the infant." "Women with postpartum depression have feelings of guilt and worthlessness." "I will make an effort to talk with someone about my feelings if I start to feel overwhelmed."
"It's common for women with postpartum depression to have delusions about the infant." Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression.
The nurse checks lab results for an adult client with suspected cancer prior to a liver biopsy. Which finding requires immediate notification of the health care provider? Elevated blood urea nitrogen (BUN) and creatinine Activated partial thromboplastin time (aPTT) of 50 seconds Increased serum ammonia Hemoglobin of 11 grams/dL
Activated partial thromboplastin time (aPTT) of 50 seconds Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding is one of the risks. An elevated aPTT increases the risk of bleeding. Abnormal findings in the other labs would not increase the client's risk of complications following a liver biopsy.
A client with considerable pain asks a nurse, "What is your opinion regarding acupuncture as a drug-free method for alleviating pain?" The nurse responds, "I'd forget about it as those weird non-Western treatments can be scary." The nurse's response is an example of what perspective? Ethnocentrism Prejudice Discrimination Cultural insensitivity
Ethnocentrism Ethnocentrism is the universal unconscious tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and therefore wrong. At a more complex level, ethnocentric people regard others as inferior or immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of their own value judgments.
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with systolic heart failure and an ejection fraction of 30%. Which other finding is most common with this diagnosis? Nail clubbing Fatigue Chest pain Peripheral edema
Fatigue Systolic heart failure is the result of a pumping problem, which is why the ejection fraction is reduced (normal is 60%). Heart failure can be caused by a heart attack, but chest pain is not normally a finding in heart failure. Nail clubbing is usually associated with disorders of the lungs. Exertional dyspnea and fatigue are common in clients with left-sided (systolic) heart failure due to fluid backing up into the lungs and pulmonary congestion. Peripheral edema is more commonly seen with right-sided (diastolic) heart failure.
A nurse asks a client with a history of alcoholism about recent drinking behavior. The client states, "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? Intellectualization Projection Rationalization Denial
Rationalization Rationalization is justifying illogical or unreasonable ideas, actions or feelings by the development of acceptable explanations for unacceptable actions. Both the teller and the listener find the rationalizations more satisfactory than the reality. Intellectualization is the use of reasoning in response to confrontation with unconscious conflicts and accompanying stressful emotions. Projection is the assignment of one's own feelings or thoughts to others.
A nurse is assessing a client two hours postoperatively after a femoral popliteal bypass to find that the upper leg dressing has become saturated with fresh blood. What should be the nurse's appropriate action? Apply pressure at the site of the bleeding Wrap the entire leg with elastic bandages Remove the old dressings with dressing reapplication Reinforce the saturated dressing with a pressure dressing
Reinforce the saturated dressing with a pressure dressing The fresh blood indicates active bleeding that need direct pressure with a pressure dressing. Because this type of surgery has long incisions the "site of the bleeding" may not be where the active bleeding is. Thus, this action is the best option of those given. The health care provider should be contacted next as the client undergoes continuous assessment for heart rate, blood pressure and respirations.
A nurse is assigned to care for a client who has been diagnosed with an intracranial aneurysm that has now stopped leaking. To minimize the risk of another bleeding episode, or rupture, the nurse should plan to take which of these actions? Avoid arousal of the client except for family visits Treat any elevation in blood pressure Apply a warming blanket for temperatures of 98 F (36.6 C) or less Keep the client in a upright sitting position
Treat any elevation in blood pressure Treating any blood pressure elevation and reducing stress by maintaining a quiet environment, including during family visits, will assist in minimizing the risk of a cerebral bleed. An upright sitting position with the pressure on the hip area can lead to increased intracranial pressure; this position should be avoided. A warming blanket is inappropriate to use.
The nurse is taking the history of a pregnant woman. Which factor should the nurse recognize as the primary contraindication for breastfeeding? Family history of breast cancer Lactose intolerance Use of cocaine on weekends Age 40-years old
Use of cocaine on weekends Binge use of cocaine can be just as harmful to the breast-fed newborn as regular daily use of cocaine.
A nurse is providing information to a client who is newly diagnosed with tuberculosis (TB). The nurse should be sure to include which statement when teaching the client about managing this disease? "Continue to get yearly tuberculin skin tests." "Continue to take your medications even when you are feeling fine." "Follow up with your primary care provider in three months." "Isolate yourself from others until you are finished taking your medication."
"Continue to take your medications even when you are feeling fine." The client with TB needs is to understand the importance of medication compliance, even when the client is no longer having any symptoms. TB treatment usually requires a combination of medications with treatment for at least six months. Stopping treatment or skipping doses can lead to a drug-resistant form of TB. Clients are most infectious early in the course of therapy but the numbers of acid-fast bacilli are greatly reduced as soon as two weeks after therapy begins. Once clients no longer have a productive cough, they are not considered contagious.
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from the home. Which statement would provide the best reality orientation for this client? "Good morning. You're in the hospital. I am your nurse Elaine Jones." "Hello. My name is Elaine Jones and I am your nurse for today." "How are you today? Remember, you're in the hospital." "Good morning. Do you remember where you are?"
"Good morning. You're in the hospital. I am your nurse Elaine Jones." As cognitive ability declines, the nurse should provide a calm, predictable environment for the client. This response establishes time, location and the caregiver's name.
A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for developing a pressure ulcer? An 80 year-old ambulatory client with a history of diabetes mellitus An obese client who uses a wheelchair An incontinent client who has had three diarrhea stools in the past hour A 79 year-old malnourished client on bed rest
A 79 year-old malnourished client on bed rest Weighing significantly less than ideal body weight increases the number and surface area of bony prominences, which are susceptible to pressure ulcers. In addition, malnutrition is a major risk factor for pressure ulcers, from poor hydration and inadequate protein intake. Note that this is a priority question so that all of the clients are at risk for pressure ulcers. However, the question asks for the client with the highest risk.
A 57 year-old male client has a hemoglobin of 10 mg/dL and a hematocrit of 32%. What would be the most appropriate follow-up by a home care nurse? Ask the client if the client has noticed any bleeding or dark stools Refer the client to schedule an appointment with a hematologist Schedule a repeat hemoglobin and hematocrit in one month Call 911 and send the client to the emergency department
Ask the client if the client has noticed any bleeding or dark stools Normal hemoglobin for males is 14 - 18 g/100 mL. Normal hematocrit for males is 42 - 52%. These values are below normal and indicate a mild anemia. The first action a nurse should take is to ask the client if the client noticed any bleeding or change in stools that could indicate bleeding from the GI tract.
A nurse is to administer meperidine (Demerol) 100 mg, atropine sulfate 0.4 mg, and promethazine (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? Instruct the client to remain in the bed Place the call bell within the client's reach Raise the side rails on the bed Assist the client to the bathroom
Assist the client to the bathroom Meperidine is a narcotic analgesic and promethazine is an antihistamine; together they can potentiate CNS effects such as drowsiness, dizziness, lightheadedness and confusion. Although all of the options involve client safety, the first thing to do is to assist the client to the bathroom to void. After administering the preoperative medications, the nurse will instruct the client to remain in bed, place the call light in the client's hand and raise the side rails.
After surgery, a client with a nasogastric tube reports feeling nauseous. What action should the nurse take? Put the head of the bed in a higher position Check the patency of the nasogastric tube Call the health care provider to troubleshoot the problem Administer an antiemetic that is ordered PRN
Check the patency of the nasogastric tube An initial indication that the nasogastric tube is obstructed is a client's report of nausea. Nasogastric tubes may become obstructed by being kinked or with mucus or sediment.
A nurse is caring for residents in a long-term care setting for the elderly. Which activity will be most effective in meeting the growth and developmental needs for persons in this age group? Aerobic exercise classes Transportation for shopping trips Reminiscence groups Regularly scheduled social activities
Reminiscence groups According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of elders as ego integrity versus despair.
The client is admitted with the diagnosis of chronic obstructive pulmonary disease (COPD). Which findings would require the nurse's immediate attention? Low-grade fever and cough Restlessness and confusion Nausea and vomiting Frequent productive cough with brownish sputum
Restlessness and confusion Hypoxia and respiratory failure in COPD may be signaled by excessive somnolence, restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, the oxygen saturation and arterial blood gases (ABGs) should be assessed and oxygen should be rapidly titrated upward to correct the hypoxia. Signs of respiratory distress or failure may necessitate the use of ventilatory assistance BIPAP or emergent intubation and mechanical ventilation. Cough, discolored sputum, and fever may indicate a respiratory infection such as pneumonia, but this is a less urgent situation.
A client who has been excessively drinking alcohol for five years states: "I drink when I get upset about ' things.' I have been unemployed. I feel like life is not leading anywhere." The nurse understands that the client is using alcohol as a way to deal with what issue? Stressors in life Feelings of anger Recreational/social needs Issues of guilt and disappointment
Stressors in life Alcohol is used by some people to manage anxiety and stress. The overall intent with this behavior is to decrease negative feelings and increase positive feelings. However, substance abuse, no matter what form or substance, eventually has an outcome of increased negative feelings.
The nurse is discussing dietary intake with an adolescent who has acne. What is the most appropriate statement by the nurse? "Do not use caffeine in any form, including chocolate." "Good nutritional habits promote healthy skin." "Decrease fatty foods from your diet." "Increase your intake of protein and vitamin A."
"Good nutritional habits promote healthy skin." The exact cause of acne is not known, but genetics and hormones (androgens) play a role. Stress, picking or squeezing blemishes and harsh scrubbing can make acne worse. While poor nutrition may make acne-prone teens more susceptible to breakouts, chocolate or greasy foods don't cause acne. Vitamin A helps regulate the skin cycle, but too much can lead to toxic side effects. Teens should simply eat an age-appropriate, well-balanced diet.
A 12 year-old pediatric cancer client is distraught about the alopecia that occurred after the last chemotherapy treatment. Which nursing interventions are appropriate for this side effect of chemotherapy? (Select all that apply.) Administer prescribed antiemetic medication before nausea is too severe Allow the child to choose a cap, scarf, wig or other head cover to use Encourage visits from friends before discharge from the hospital Practice and teach thorough hand washing
Allow the child to choose a cap, scarf, wig or other head cover to use Encourage visits from friends before discharge from the hospital Alopecia is the loss of hair, which is a frequent side effect of certain types of chemotherapy. Although it is not life-threatening, the body image change is difficult for many individuals, particularly children and adolescents. Encouraging visits from friends before discharge helps the young client and friends adjust. Wearing preferred forms of head cover-ups increases comfort and decreases embarrassment. The other options are proper interventions for chemotherapy, but do not help the client with hair loss.
The nurse is reviewing age-appropriate diagnoses for older adults. Which nursing diagnosis would indicate that the client is at greatest risk for falling? Altered patterns of urinary elimination related to nocturia Impaired gas exchange related to retained secretions Alteration in mobility related to fatigue Sensory perceptual alterations related to decreased vision
Altered patterns of urinary elimination related to nocturia Nocturia is especially problematic because many older adults fall when they rush to reach the bathroom during the night. They may be confused or not fully alert because of having been asleep. Inadequate lighting can increase their chances of stumbling, and then they may fall over furniture or carpets. Note that the question asks for the greatest risk, so that all of the options are correct and associated with falls. However, altered patterns of elimination are the most common risk for falls.
A 80 year-old client diagnosed with pneumonia is exhibiting new onset confusion. The client is pulling at tubes and items near the bed and trying to get out of bed. Which intervention would be most appropriate? Arrange for a sitter to stay with the client Frequently remind the client to stay in bed Request an order for wrist restraints Request an order for antianxiety medication
Arrange for a sitter to stay with the client The plan to use safety protective devices such as wrist restraints should be rethought with a review of other safe actions. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These should be provided by the facility in the event the family cannot do so. This client who has a lung infection and productive cough needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
A child is injured on the school playground and appears to have a fractured leg. Which of the following is the first action a school nurse should take? Assess the child and the extent of the injury Call for emergency transport to the hospital Apply cold compresses to the injured area Immobilize the limb and joints above and below the injury
Assess the child and the extent of the injury Application of the nursing process dictates that assessment is the first step in the provision of care. The 6 Ps of vascular impairment (pain, pulse, pallor, paresthesia, paralysis and poikilothermia (coolness) can be used as a guide for assessment of the injured leg. The other options would be done in this sequence - immobilize, call 911 and then apply ice as indicated.
A nurse manager considers changing staff assignments from 8-hour shifts to 12-hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. The nurse manager should first take what action? Support the planning committee and post the new schedule Explore how the planning committee evaluated barriers to the plan Design a different approach to deliver care with fewer staff Retain the previous staffing pattern for another six months
Explore how the planning committee evaluated barriers to the plan A manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated. The manager wants to build the staff's skills at implementing change. Helping the committee evaluate its decision making is a useful step before rejecting or implementing the change. When possible, all affected by the change should be involved in the planning. The question is whether staff input has been thoroughly taken into consideration. This also illustrates the application of the nursing process to nonclient-care issues with assessment of the situation being the first step.
A woman in early labor puts her call light on and tells the nurse "I think my water bag just broke and I feel like something came out with the water." A visual exam by the nurse reveals a prolapsed umbilical cord. List in order of priority the actions the nurse should perform in this obstetrical emergency. Place the client in a knee-chest position on the bed Administer oxygen to the mother via mask at 10 L/min Call for assistance, asking that the health care provider is notified Glove and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure
Glove and place two fingers into the cervical opening, beside the umbilical cord, to relieve pressure Call for assistance, asking that the health care provider is notified Place the client in a knee-chest position on the bed Administer oxygen to the mother via mask at 10 L/min A prolapsed cord is a medical emergency; the blood flow from the placenta to the fetus will be occluded with each contraction if the umbilical cord is compressed against the presenting part of the fetus and the dilated cervix which is why the priority intervention is to apply gloves and place two fingers to one side of the cord (or entire hand) to relieve pressure. The nurse is also calling for assistance so that someone can notify the health care provider and staff can prepare for emergent cesarean. Placing the client in a modified Sims or knee-chest position will allow gravity to help decrease pressure on the cord from the presenting part, but the primary relief from pressure on the umbilical cord is the gloved fingers. Oxygen administration will help once the circulation of blood to the fetus is re-established.
A nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by which action? Hyperoxygenation with 100% O2 for one to two minutes before and after each suction pass Complete a suction pass in 30 seconds with a pressure of 150 mm Hg Minimize a suction pass to 60 seconds while slowly rotating the lubricated catheter Insertion of a fenestrated catheter with a whistle tip without suction
Hyperoxygenation with 100% O2 for one to two minutes before and after each suction pass The nurse would administer supplemental 100% oxygen through the mechanical ventilator or using a manual resuscitation bag for one to two minutes before, after and between suctioning passes to prevent hypoxemia.
The nurse is assessing a 1 month-old infant. Which finding should the nurse report immediately? Increased heart rate with crying Abdominal respirations Irregular breathing rate Inspiratory grunt
Inspiratory grunt Inspiratory grunt is an abnormal finding and indicates respiratory distress in infants. Other signs of respiratory distress in this age group are nasal flaring, often the initial finding, as well as sternal and intracostal retractions. Abdominal breathing is a normal expected breathing process for infants. The other findings are also normal in infants.
The home health nurse observes the client change an ileostomy pouch. Which action is best to help prevent skin breakdown? Change the stoma pouch daily Use deodorant soaps the contain lotion to clean the stoma Make sure the skin around the stoma is wrinkle-free Apply antiseptic cream to reddened stoma
Make sure the skin around the stoma is wrinkle-free The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal.
A nurse is teaching a newly diagnosed client with asthma how to use a peak flow meter. The nurse should explain that it is to be used to achieve which outcome? Determine the client's oxygen saturation Provide metered doses for inhaled bronchodilator Monitor atmosphere for presence of allergens Measure forced expiratory volumes
Measure forced expiratory volumes The peak flow meter is used to measure peak expiratory flow volumes. It provides useful information about the presence and/or severity of airway obstruction. If the result falls in the green, the client is good without any problems. If it falls into the yellow or red category, immediate action is required. The specific action should be determined with the health care provider ahead of time before this happens. Often the clients are advised to use a bronchodilator inhaler and then recheck for improvement. When teaching the colors for the peak flow meters, nurses often associated the colors and actions with those of a traffic light. Green = go; yellow = proceed with caution; and red = stop and get help.
A 10-month old infant is admitted with a diagnosis of bacterial meningitis. Several hours after admission, during a planning conference, which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) would be appropriate to add to the plan of care? Provide an over-the-crib protective top Measure head circumference Provide passive range of motion Initiate droplet precautions
Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client would have already been placed on droplet precautions and had a crib top applied to the bed when he was admitted to the unit.
The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Readjust the traction for comfort Administer the ordered PRN medication Notify the health care provider Reassess the extremity in 15 minutes
Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.
The nurse has been teaching a client diagnosed with heart failure about proper nutrition. Which of these lunch selections indicates that the client has learned about sodium restriction? Sliced turkey sandwich with a side of canned pineapple Cheeseburger and baked potato with butter Cheese sandwich with a glass of 2% milk Mushroom pizza and ice cream made from whole milk
Sliced turkey sandwich with a side of canned pineapple Sliced turkey sandwich is appropriate because it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
