NCLEX 14
A nurse reviews the history of a client diagnosed with depression from an earlier admission. Documentation of anhedonia is noted. What should the nurse understand about this note in the client's history? A lack of enjoyment in usual pleasures in life A report of difficulty falling and staying asleep A reduced senses of taste and smell An expression of persistent suicidal thoughts
A lack of enjoyment in usual pleasures in life All of the responses could be associated with a diagnosis of depression, including "anhedonia," which means the inability to experience pleasure or the loss of interest in previously rewarding or enjoyable activities. Anhedonia is one of the main symptoms of major depressive disorder (MDD).
After four electroconvulsive treatments over two weeks, a client is very upset and states, "I am so confused. I lose my money. I just can't remember telephone numbers." The most therapeutic response for the nurse to make is which of these statements? "I can hear your concern and that your confusion is upsetting to you." "Don't get upset. The confusion will clear up in a day or two." "You were seriously ill and needed the treatments." "It is to be expected since most clients have the same results."
"I can hear your concern and that your confusion is upsetting to you." Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed with a movement to the problem-solving stage.
A 19 year-old client is paralyzed in a car accident. Which statement would indicate that the client is using the mechanism of "suppression"? "My mother is heartbroken about this." "I'd rather not talk about it right now." "I don't remember anything about what happened to me." "It's all the other guy's fault! He was going too fast."
"I don't remember anything about what happened to me." Suppression is willfully putting an unacceptable thought or feeling out of one's mind. A deliberate exclusion, "voluntary forgetting," is generally used to protect one's own self-esteem.
During initial evening rounds, the nurse notices a foul smell in the room of a client diagnosed with pneumococcal pneumonia who was started on intravenous antibiotics 10 hours ago. The client makes all of these statements during their conversation. Which one would alert the nurse to a potential complication of this diagnosis? "I have been sweating off and on all day" "I feel hot off and on, especially when I lie in bed." "I have a sharp pain in my chest when I take a breath." "I have been coughing up foul-tasting, brown, thick sputum."
"I have been coughing up foul-tasting, brown, thick sputum." Foul smelling and tasting sputum signals the possible development of a lung abscess, a complication of pneumonia, particularly in aspiration pneumonia. This puts the client in grave danger because abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for any type of infection.
A client has many delusions. As a nurse helps the client prepare for breakfast the client comments, "Don't waste good food on me. I'm dying from this disease I have." What is an appropriate response by the nurse? "You need some nutritious food to help you regain your weight." "None of the laboratory reports show that you have any physical disease." "Try to eat a little bit, breakfast is the most important meal of the day." "I know you believe that you have an incurable disease."
"I know you believe that you have an incurable disease." This response does not challenge the client's delusional system. Thus, the statement forms an alliance by providing reassurance of a desire to help the client.
A pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Which findings observed by the nurse would be associated with this problem? Hearing loss and ataxia Headaches and vomiting Abdominal mass and weakness Lymphedema and nerve palsy
Abdominal mass and weakness Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline. The first findings are usually fever, weakness, pallor, anorexia, weight loss and irritability. In most clients, the neuroblastoma has already spread when it is first diagnosed.
A client is recently diagnosed with Barrett's esophagus. Which of the following statements made by the client demonstrates that further teaching is needed about this illness? "I will need regular endoscopies to monitor this illness." "I should avoid eating anything for two hours before I go to sleep." "I should try to sleep lying on my right side." "I will have to cut back on my smoking."
"I will have to cut back on my smoking." Barrett's esophagus is a complication of gastroesophageal reflux disease (GERD) and is associated with an increased risk for esophageal cancer. Endoscopies are scheduled regularly to monitor the progression of the disease and to catch any cancer in its earliest stages. Treatment for Barrett's esophagus is the same as for GERD. Lifestyle changes include weight loss, avoiding acidic foods and fluids, not eating 90-120 minutes before bedtime, and sleeping with the head of the bed elevated or in a right side-lying position. Cutting back on smoking is too ambiguous; since smoking aggravates GERD and is linked to the development of cancer, this client should be advised about smoking cessation programs.
A nurse explains an autograft to a client scheduled for excision of a skin tumor. Which of the following statements indicates the client understands the procedure? "I will receive tissue from a tissue bank." "I will receive tissue from a pig." "I will receive tissue from synthetic skin." "I will receive tissue from my thigh."
"I will receive tissue from my thigh." Autografts are done with tissue transplanted from the client's own skin. Tissue from a pig is called a xenograft or heterograft, which means it is transplanted from an organism of one species to that of a different species. Cadaveric grafts are termed allografts, or homografts because they are transplanted from one individual to another within the same species.
A client is admitted for placement of a suprapubic catheter. Which statement by the client should the nurse identify as a misunderstanding of self-care? "I will rinse the drainage bag with bleach once a week." "I will let my health care provider know if my urine looks cloudy." "I will change the catheter every month." "I will drink lots of fluids to stay well-hydrated."
"I will rinse the drainage bag with bleach once a week." A suprapubic catheter is an indwelling urinary catheter that has been surgically placed to drain urine from the bladder. The client will need to change the catheter approximately once a month. To help decrease infections, the client should drink plenty of fluids, especially after changing the catheter. If the client notices a smell or change in color of the urine or the urine is cloudy, the client should call the health care provider. To clean the drainage bag, the client can disconnect the bag, swish some warm soapy water around in it and then rinse the bag with a vinegar solution - never bleach. This can be done every few days or so. This client needs additional instruction on the proper care of the drainage bag.
The nurse is caring for a 68 year-old client who had a total hip replacement three days ago. Which assessment finding requires the nurse's immediate attention? "I have to use the bedpan to pass my water at least every hour." "It seems that the pain medication is not working as well today." "I have bad muscle spasms in my lower leg, below the incision." "I've been having a lot of trouble breathing for the past few minutes. I have a really bad feeling about this."
"I've been having a lot of trouble breathing for the past few minutes. I have a really bad feeling about this." The nurse would be concerned about all of these comments, however the most life threatening is the respiratory focus (think ABCs). Clients who have had hip or knee surgery are at risk for developing pulmonary embolism. Sudden dyspnea, tachycardia and a feeling of impending doom are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Frequent urination may indicate a urinary tract infection, particularly since the client likely had an indwelling urinary catheter during surgery. Although the thought that medication is not effective requires further investigation, it is not life-threatening.
A nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best? "Let us discuss your rights as a couple" "What is your reason for wanting such a plan?" "Write your ideal plan for the next class" "Have you talked with your provider about this?"
"Let us discuss your rights as a couple" Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan. To write an ideal plan is not a realistic nor the best approach because this approach does not often allow for complications.
A client who is recovering from alcoholism asks a nurse, "What can I do when I start to recognize relapse triggers within myself?" How might the nurse respond? "When you have an impulse to stop in a bar, contact sober friends and talk with them." "Go to an AA meeting that week when you feel the urge to drink." "Let's talk about possible options you have when you recognize these relapse triggers in yourself." "Exercise daily and get involved in activities that will cause you not to think about drinking."
"Let's talk about possible options you have when you recognize these relapse triggers in yourself." This option encourages the process of self-evaluation and problem solving and provides an avoidance of telling the client what to do. Encouraging the client to brainstorm about response to relapse trigger options validates the nurse's belief in the client's personal competency. These behaviors reinforce a coping strategy that will be needed when the nurse is not available to offer solutions.
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which action would be most appropriate? Ambulate in hallway four times a day Administer analgesic therapy as ordered Encourage increased caloric intake Fluid restriction 1000 mL per day
Administer analgesic therapy as ordered The main general interventions in the treatment of a sickle cell crisis are bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement, and antibiotics (to treat an existing infection).
The parents of a toddler who is being treated for pesticide poisoning ask, "Why is activated charcoal used? What does it do?" Which of these statements is the best way for the nurse to respond? "The activated charcoal binds with the poison to limit absorption from the digestive tract." "The charcoal stimulates bowel evacuation." "The action may bind or inactivate the toxins or irritants that are ingested by children and adults." "This substance helps to get the poison out of the body through the gastrointestinal system."
"The activated charcoal binds with the poison to limit absorption from the digestive tract." All of the options are correct responses. However, the correct answer is the most accurate information to answer the parents' questions about the use and action of activated charcoal. The language is appropriate for the parents' understanding.
A mother telephones the clinic and says, "I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding." A nurse's best response would be which of these? "The stool should have turned to light brown by now. We need to test the stool." "Water should be offered several times each day in addition to the breast-feeding." "This type of stool is normal for breast-fed infants. Keep doing as you have." "Formula supplements might need to be added to increase the bulk of the stools."
"This type of stool is normal for breast-fed infants. Keep doing as you have." In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.
Which of the following methods are used to correctly identify a client? (Select all that apply.) Ask a family member or visitor Check the client identification bracelet Compare the client to a labeled photograph Ask clients to state their name Have clients state their birth date
Check the client identification bracelet Compare the client to a labeled photograph Ask clients to state their name Have clients state their birth date Two pieces of identification are required prior to any procedure, including medication administration. Because client identification bracelets are not routinely used in long-term care facilities, nurses use a photograph to identify a resident. Visitors and even family members should not be asked to identify clients.
A nurse is teaching parents about accidental poisoning in children. Which action should the nurse emphasize that the parents initially take if there is a suspected poisoning? Do not induce vomiting if the poison is a hydrocarbon Keep the child as quiet as possible if a toxic substance was inhaled Call the Poison Control Center once the situation is identified Empty the child's mouth in any case of a possible poisoning
Empty the child's mouth in any case of a possible poisoning Emptying the mouth of poison prevents further ingestion and should be done first to limit damage from the substance. Note that all of the actions are correct, but emptying the mouth is the priority.
The client is a 7 year-old child with a fractured femur and extensive skin damage. Which type of traction does the nurse expect will be used? Buck's traction Russell traction Bryant's traction 90-90 traction
90-90 traction For fractures of the femur or tibia in children in this age group, a 90-90 traction is used, that is, the hip is flexed up to 90 degrees and the knee is also flexed at 90 degrees. Either skin traction or skeletal traction can be used. In skeletal traction, a skeletal pin or wire is surgically placed through the distal part of the femur (and the lower part of the extremity is in a boot cast.) Traction ropes and pulleys are applied.
Staffing includes several registered nurses (RNs) and one licensed practice nurse (LPN). Which of these clients should the charge nurse assign to an RN? A 24 year-old post-op client newly diagnosed with type 1 diabetes mellitus, who is in the process of being discharged A 60 year-old client with a history of asthma and reports shortness of breath using oxygen at 2 L/min A 56 year-old diagnosed with atrial fibrillation who recently started taking dabigatran (Pradaxa) An 80 year-old client recovering 24 hours post right hip replacement
A 24 year-old post-op client newly diagnosed with type 1 diabetes mellitus, who is in the process of being discharged The RN can delegate the care of a client if it is not too complex or variable, and there is a low likelihood of emergency. Also, only RNs can teach; LPNs can reinforce the plan or care and information already taught by the RN. Therefore, discharge teaching can only be done by the RN.
A nurse is caring for a 2 year-old child after corrective surgery for tetralogy of Fallot. The mother reports that the child has suddenly begun having a seizure. The nurse should recognize that this situation is most likely from which complication? Postoperative meningitis A cerebral infarction Metabolic alkalosis Medication reaction
A cerebral infarction Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebral infarctions, also called cerebrovascular accidents, may occur. Findings include sudden degrees of paralysis, altered speech, extreme irritability or fatigue, and grand mal seizure activity accompanied with incontinence of bowel and bladder.
A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? Completely crushing all medications prior to administration Adequately flushing the tube with water before and after use Squeezing the tube to dislodge obstructions Encouraging the client to cough to relieve abdominal blo
Adequately flushing the tube with water before and after use Prior to using the tube, it must be checked to make sure it is free from obstruction and leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after use is the best way to ensure patency (while providing hydration). Liquid medication preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the client to cough, which will speed up the removal of excessive air, but the tube still needs to be flushed with water before and after use.
The client is recovering from an acute myocardial infarction. In order to prevent complications associated with the Valsalva maneuver in this client, what action should the nurse take? Administer antiarrhythmic medications PRN as ordered Assist the client with use of the bedside commode Administer stool softeners every day as ordered Maintain the client on strict bed rest
Administer stool softeners every day as ordered After myocardial infarction, the Valsalva maneuver can cause cardiac arrhythmias. Administering stool softeners every day will prevent the client from straining or bearing down on defecation (the Valsalva maneuver). If constipation occurs, laxatives would be necessary to prevent Valsalva. If the client experiences cardiac arrhythmias associated with straining on defecation, then administering antiarrhythmics would be appropriate. Maintaining bed rest with use of a bedpan can increase the likelihood of straining and difficulty with defecation as well as increased myocardial oxygen consumption, so use of the bedside commode is also appropriate to achieve this goal in this client.
A client with a history of asthma is admitted for a minor surgical procedure. Preoperatively, the peak flow is measured at 480 liters/minute. Postoperatively the client reports chest tightness and the peak flow is now 200 liters/minute. What action should the nurse now take? Notify both the surgeon and primary care provider Administer the PRN dose of albuterol Repeat the peak flow reading in 30 minutes Apply oxygen at two liters per nasal cannula
Administer the PRN dose of albuterol Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta agonist must be taken immediately. Notifying the health care provider is important, but that is not what would be done first. First, the client needs assistance. Oxygen administration will not be effective if the airway constriction is not relieved with the albuterol. Leaving the client and returning in 30 minutes will do nothing to help a client in acute distress.
A 2 year-old child has recently been diagnosed with cystic fibrosis. A nurse is teaching the parents about home care for the child. Which piece of information is appropriate for the nurse to include? Allow the child to continue normal activities Limit exposure to other children Restrict activities to inside the house Schedule frequent rest periods
Allow the child to continue normal activities Physical activity is important in a 2 year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucus secretion and helps develop normal breathing patterns.
A health care provider has ordered nitroglycerin transdermal (Nitro-Dur) patches for a client. Which of these instructions should be included by the nurse when teaching a client about how to use the patches? Apply the patch to any nonhairy area of the body Remove the patch when swimming or bathing Apply a second patch with chest pain Remove the patch if ankle edema occurs
Apply the patch to any nonhairy area of the body The patch application sites should be rotated on body areas of the least amount of hair. If a client has poor lower leg arterial circulation, the ankle areas should be avoided.
The nurse is providing the client who takes digoxin and furosemide with dietary instructions. The nurse should reinforce that the combination of these medications can result in which outcome? Irritability and excitability Oliguria Arrhythmias Weight gain
Arrhythmias Furosemide is an effective diuretic but electrolyte depletion may occur. Concurrently taking furosemide and digoxin exaggerates the metabolic effects of hypokalemia, especially alterations in cardiac rate and rhythm, and contributes to digitalis toxicity. Digitalis toxicity may stimulate almost every known type of dysrhythmia. The effects of hypokalemia include fatigue (not excitability) and polyuria (not oliguria); digitalis toxicity can cause nausea, vomiting, anorexia and weight loss (not weight gain). Foods rich in potassium include avocados, bananas, peas and beans, spinach and tomatoes.
During the initial physical assessment on a client who is a Vietnamese immigrant, a nurse notices small, circular, ecchymotic areas on the client's knees. What is the best action for the nurse to take at this time? Report the bruising to social services for follow-up Document the findings on the admission sheet Discuss with the client and then the family about the findings Ask the client for more information about the nature of the bruises
Ask the client for more information about the nature of the bruises "Cupping" is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness. There is no need to ask or discuss with an adult's family members.
A nurse is caring for a child diagnosed with Reye's syndrome. Which action should be given the highest priority by the nurse? Provide good skin care Assist with range of motion Monitor intake and output Assess level of consciousness
Assess level of consciousness An altered or decreased level of consciousness suggests increased intracranial pressure related to cerebral edema in the child with Reye's syndrome.
The nurse admits a client with a diagnosis of hepatitis B. Which serum lab value would the nurse expect to be elevated? Bilirubin Acid phosphatase Blood urea nitrogen (BUN) Sedimentation rate
Bilirubin In the laboratory data provided, the only elevated level expected is bilirubin with a diagnosis of hepatitis B. BUN is elevated in situations of dehydration, excessive protein breakdown and renal failure. Elevated sedimentation rate reflects an abnormal process in the body without any specific associated problem.
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. What should the nurse be sure to teach the parents about caring for their child at home? Place the favorite books and push-pull toys in the crib Turn the baby with the abduction stabilizer bar every two hours Check every few hours for the next day or two for swelling in the baby's feet Gently rub the skin with a cotton swab to relieve itching
Check every few hours for the next day or two for swelling in the baby's feet A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation. For children beyond the neonatal period, traction and/or surgery followed by hip spica casting are usually needed.
A nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube and the drainage tube is lying on the floor. What immediate action should the nurse take? Clamp the chest tube with a rubber tipped hemostat Call the health care provider for directions Raise the end of the chest tube as high as possible Reconnect the drainage tube to the chest tube
Clamp the chest tube with a rubber tipped hemostat Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client's chest is the first action to take. The use of rubber tipped hemostats prevents cutting into the chest tube to prevent placement of holes into the tube. Then after retrieval of a new chest drainage collection system and setting it up, the chest tube can be reconnected to the drainage tube with the use of sterile technique.
A nurse is caring for a client who is one day postop following a thoracotomy. The client has two chest tubes that are connected to one chest drain system. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the appropriate nursing action? Call the surgeon immediately for potential return to surgery Continue to monitor the client to see if the bubbling increases Instruct the client to avoid coughing for the next day Clamp one of the chest tubes and ask the client to cough again
Continue to monitor the client to see if the bubbling increases Bubbling in the water seal chamber that is associated with coughing after lung surgery is an expected finding within the first 48 hours postop. Small amounts of air escape into the pleural space when pressures inside the chest increases with coughing. Monitoring for increases or decreases in the bubbling with coughing is the only nursing action required at this time. The client should be encouraged to deep breathe and cough every two hours minimally.
The nurse is administering an enteral feeding to a client via a jejunostomy tube. With which frequency would the nurse administer the formula? Every hour Every four to six hours In a bolus Continuously
Continuously Usually small intestinal feedings, such as jejunostomy feedings, are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula. Gastric feedings are more often given in a bolus every so many hours.
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes that which finding may indicate the client is having a negative side effect from the medication? Decreased appetite Gastric irritability Weight gain of five pounds Edema of the ankles
Decreased appetite Furosemide causes a loss of potassium if a supplement is not taken. Findings of hypokalemia include anorexia, fatigue, nausea, decreased gastrointestinal motility, muscle weakness and dysrhythmias.
What is the major purpose of community health research? Evaluate illness in the community Explain the health conditions of families Describe the health conditions of populations Identify the health conditions of the environment
Describe the health conditions of populations Community health focuses on aggregate population care.
A female client diagnosed with genital herpes simplex virus 2 (HSV-2) reports having dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. Which intervention will provide symptomatic relief? (Select all the apply.) Dry the genital area with a blow dryer on the cool setting Soak in a tub of hot water Echinacea juice extract capsules twice daily Increase fluid intake Local application of ice packs Over-the-counter medications such as ibuprofen
Dry the genital area with a blow dryer on the cool setting Local application of ice packs Over-the-counter medications such as ibuprofen Symptomatic relief includes lukewarm (not hot) baths and applying cold packs to the genital area. Sometimes using a hair dryer set to a low or cool setting can help relieve symptoms. Over-the-counter medications such as ibuprofen and acetaminophen can help with local tenderness. A client with HSV-2 should increase their fluid intake when using acyclovir, but increasing fluids will not directly relieve symptoms. There's no evidence that echinacea can relieve the symptoms of HSV-2.
The nurse is caring for a client following total knee replacement surgery. Which intervention will be most effective in preventing the complication of deep vein thrombosis in this client? Place pillows under the knees Encourage range of motion and ambulation Use elastic stockings continuously Massage the legs twice daily
Encourage range of motion and ambulation Mobility reduces the risk of deep vein thrombosis (DVT) in the postsurgical client. The postoperative client would wear either compression elastic stockings and/or external pneumatic compression devices; elastic stockings should be removed at least once a shift to assess skin integrity. Pillows should never be placed under the knees, as it can prevent appropriate venous return.
The nurse is caring for a 14 year-old boy diagnosed with hemophilia A. The client was admitted after a fall while playing basketball. In understanding the client's behavior, and in planning care for this client, the nurse should understand what focus is associated with adolescents diagnosed with hemophilia? Exercising and taking part in sports are important Physical limitations must be explained to peer groups Implications of taking risks after acute bleeding episodes should be emphasized Alternative sedentary and structured activities should be discussed
Exercising and taking part in sports are important An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescents diagnosed with hemophilia should be aware that contact sports may trigger bleeding episodes. However, developmental characteristics of this age group, such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. In order to prepare for the "unfreezing" phase of change, the nurse manager should take which approach? Clarify what the changes mean to the community and the hospital Discuss with the staff how to deal with any defensive behavior Explain to the unit staff why change is necessary Assist the staff for an acceptance of the new changes
Explain to the unit staff why change is necessary The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it and explains this to the staff. The phase is completed when the staff comprehend the need for change.
A client diagnosed with gouty arthritis is admitted with severe pain and cellulitis of the right foot. Which intervention should be included when the nurse develops the plan of care? Active range of motion exercises High protein diet Hot compresses to affected joints Fluid intake of at least 3000 mL/day
Fluid intake of at least 3000 mL/day Fluid intake should be increased to prevent precipitation of urate in the kidneys; a lack of sufficient fluids enhances the formation of urate renal calculi or kidney stones. Treatment for acute attacks include supportive measures, such as applying ice and resting the affected joint. The client should avoid eating foods high in purines, such as organ meats (liver), and limit eating beef, pork and lamb.
A 2 year-old child is being treated with amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 33 lb (15 kg) and the daily dose range is 20 to 40 mg/kg of body weight, in three divided doses every eight hours. Using principles of safe drug administration, what should a nurse do next? Recognize that antibiotics are over-prescribed Hold the medication because the dosage is too low Call the health care provider to clarify the dose Give the medication as ordered
Give the medication as ordered Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20 to 40 mg/kg/day divided every eight hours; 15 kg x 40 mg = 600 mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.
A nurse should question the use of atropine as a treatment for symptomatic bradycardia in which of these conditions? Glaucoma Urinary incontinence Right-sided heart failure Increased intracranial pressure
Glaucoma Atropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary dilation with an increase in aqueous humor. This leads to an increase in optic pressure.
A nurse is assessing a 4 month-old infant. Which motor skill should the nurse anticipate finding? Drink from a cup Hold a rattle Bang two blocks Wave "bye-bye"
Hold a rattle The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
A client with amyotrophic lateral sclerosis (ALS) is scheduled for 160 mL of enteral feeding as a bolus every four hours. Prior to the next feeding and before flushing with water, a nurse aspirates the feeding tube and gets back 180 mL of gastric contents as residual. What is the next appropriate nursing action? Administer the feeding as ordered Discard the undigested gastric contents Flush with sterile water Hold this planned feeding
Hold this planned feeding If residual from a feeding tube is greater than 150 mL, then the feeding should be held. The residual should be reinserted into the feeding tube. Administration of water or the feeding does not help with the digestion of the prior feeding. Discarding the feeding that was aspirated is an incorrect action because such removal and discarding depletes the body of enzymes and electrolytes that have been mixed with the earlier feeding.
The visiting nurse makes a postpartum visit to a married female client and her husband. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. What should be the initial nursing intervention? Confront the husband about the condition of his wife Interview the client in a private place in the home to determine the origin of the injuries Leave the home because of the unsafe environment Call the police to report indications of domestic violence
Interview the client in a private place in the home to determine the origin of the injuries It is a correct approach to assume domestic violence with further assessment. Separate the suspected abused person from the partner until any battering has been ruled out by conversation in a private location in the home. No information is given of the situation that would warrant to leave or to call the police. To confront the partner is never a correct approach. This should be left to the authorities.
A nurse is teaching an 87 year-old client methods to maintain regular bowel movements. Which product would the nurse caution the client to avoid? Laxatives Stool softeners Fiber supplements Glycerine suppositories
Laxatives Some older adults are constipated because they have used over-the-counter laxatives for a long time. The bowel can get dependent on this stimulus. In addition, this group of people do not eat enough fiber, drink enough water, or exercise adequately. Certain medications, including opioid analgesics during long-term use, result in constipation or impaction from the decrease in peristalsis.
A nurse is assigned to care for a client diagnosed with deep vein thrombosis who is receiving IV heparin. The latest aPTT is 50 seconds. If the laboratory normal range is 16 to 24 seconds, the nurse should anticipate taking which action? Check to see if protamine sulfate can be ordered as an antidote Call to increase the heparin dosage as it does not appear therapeutic Repeat the blood test one hour from this blood result Maintain the current heparin dosage
Maintain the current heparin dosage The range for a therapeutic aPTT is generally 1.5 to 2 times the control values. Therefore, the client is getting a therapeutic dose of heparin.
While caring for a client during the first hour after delivery, a nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? Massage the fundus Check for perineal lacerations Check vital signs Offer a bedpan
Massage the fundus The nurse's first action should be to massage the fundus supporting the lower uterine segment until it is firm. Uterine atony is the primary cause of bleeding in the first hour after delivery.
resection of the prostate (TURP) 12 hours ago. The client has an indwelling 3-way catheter with continuous bladder irrigation. Which finding requires the nurse's immediate intervention? Light-pink urine with a continuous stream into the collection bag Minimal drainage into the urinary collection bag Reports of a feeling of discomfort from the urinary catheter Occasional suprapubic cramping about every hour
Minimal drainage into the urinary collection bag All of the options, except the lack of drainage into the collection bag, are expected findings after this procedure. Urine will be bright red from bleeding immediately after the procedure, lightening over time as bleeding decreases. A lack of drainage needs to be reported immediately because minimal urinary drainage puts the client at risk for bladder rupture. The cause of this is likely to be a blood clot in the catheter or obstructing the catheter tip, which requires sterile irrigation of the catheter to restore its patency. The flow rate of the continuous irrigation would need to be slowed until urine flow has been restored. In some facilities, an order for syringe bladder irrigation as needed is a standing order accompanying the orders for continuous bladder irrigation.
The client walks into the emergency department with findings consistent with tuberculosis (TB) disease, including cough, loss of appetite, night sweats and bloody sputum. Which of these initial nursing actions is indicated? Measure and fit the client with a N95 disposable respirator Provide instruction to the client about cough etiquette Move the client into an airborne infection isolation (AII) room Notify all staff members about the client with TB disease
Move the client into an airborne infection isolation (AII) room The priority is to initiate TB airborne precautions for any client with symptoms of TB disease and to place him/her in a AII room (if available in the facility). Health care workers (and visitors) should wear at least N95 disposable respirators before entering an AII room. Only those having contact with the client need to be informed on the client's (unconfirmed) condition. When the client is transported to another area of the hospital, s/he will wear a surgical or procedure mask. The nurse can teach the client about cough etiquette, but this is not a priority.
A nurse is assigned to an 83 year-old client with Parkinson's disease. Which findings would the nurse anticipate? Muscle spasm and a bent over posture Voluntary tremor and jerky movement of the elbows Muscle rigidity and a shuffling gait Nonintention tremors and urgency with voiding
Muscle rigidity and a shuffling gait Clients with Parkinson's disease have a very distinctive gait with quick short steps (shuffling) that may increase in speed so that they are unable to stop, as well as muscle rigidity. In the other options, only one of the two findings listed is associated with Parkinson's disease: clients may have nonintention tremors, but there is no urgency with voiding; their posture may be "bent over," but there are no muscle spasms; and while they may experience a cogwheel or jerky movement of the elbows, their tremors are not voluntary.
A client exhibits hyperventilation and physical findings consistent with this problem. Which oxygen delivery system should the nurse use with this finding? Partial rebreather mask Venturi mask Nonrebreather mask Simple face mask
Partial rebreather mask The client with hyperventilation is likely experiencing respiratory alkalosis, as a result of "blowing off" the acid carbon dioxide. The use of a partial rebreather mask will allow the client to rebreath some of the exhaled carbon dioxide, which will help restore balance to the client's acid-base status, correcting the respiratory alkalosis.
A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse should understand that this medication spares elimination of which element? Potassium Albumin Sodium Phosphate
Potassium If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as spironolactone (Aldactone) should be administered. Potassium-sparing diuretics will inhibit the action of aldosterone on the kidneys.
A 10 year-old child is recovering from a splenectomy after a traumatic injury. The child's laboratory results show a hemoglobin of 8.8 g/dL and a hematocrit of 26%. What is a priority approach that the nurse should include in the plan of care? Plan for regularly scheduled rest periods Restrict the consumption of carbonated beverages Promote a diet rich in iron and lean red meats Encourage bed activities and games for the next five days
Plan for regularly scheduled rest periods The initial priority for this client is rest due to the lack of sufficient red blood cells to carry oxygen. The normal hemoglobin is between 10.0 and 15.0 g/dL, and the normal hematocrit is 35% to 45% for a child this age. Note that all of the options are correct actions that may be used for various reasons.
The nurse observes 4 year-old children playing in the hospital playroom. What activity does the nurse expect to see? Playing alone with hand-held computer games Playing with their own toys alongside other children Playing competitive board games with older children Playing cooperatively with other preschoolers
Playing cooperatively with other preschoolers Older preschoolers (4 years) will develop the necessary social, problem-solving and creative skills by playing with friends and engaging in simple games and activities. This is cooperative play. Younger preschoolers (3 years) and older toddlers engage in parallel play (playing with their own toys next to other children) or associative play (playing separately, but talking to each other.) School-age children follow rules designed by others, as in board games.
A client is brought to the emergency department with a blood sugar of 48 mg/dL. The client is weak and diaphoretic but awake, and the client's blood sugar does not rise after drinking two 8-ounce glasses of orange juice. Which of the following actions should be taken? (Select all that apply.) Offer a cola with added sugar Recheck blood sugar in 15 minutes Offer milk or cheese Determine blood sugar management medications Instruct the client to not take more insulin today
Recheck blood sugar in 15 minutes Offer milk or cheese Determine blood sugar management medications A sugar below 50 must be treated. Newer oral hypoglycemic agents affect the blood sugar level over longer periods of time, so there may not be an immediate response to simple carbohydrates. After a period of metabolizing more complex carbohydrates, the blood sugar level should rise.
The nurse measures the head circumference and chest circumference of a 18 month-old infant. The nurse compares the two measurements to each other and notes they are approximately the same. What action should the nurse take? Notify the health care provider Palpate the anterior fontanel Record the findings in the chart Feel the posterior fontanel
Record the findings in the chart These are expected findings and the nurse will record the measurements in the client's chart. Between 6 months and 2 years, an infant's head circumference and chest circumference measurements are about the same. A newborn's head is usually about 2 centimeters larger than the chest size; after age 2 years, the chest size becomes larger than the head.
A client is taking tranylcypromine (Parnate) and has received dietary instructions. Which food selection would be contraindicated for this client? Fresh juice, carrots, vanilla pudding Red wine, fava beans, aged cheeses Hamburger, fries, strawberry shake Apple juice, ham salad, fresh pineapple
Red wine, fava beans, aged cheeses Red wine and cheese contain tyramine, as do chicken livers and ripe bananas. Foods containing tyramine are contraindicated when taking an MAOI like tranylcypromine. Fava beans contain other vasopressors that can interact with MAOIs, causing malignant hypertension.
The RN is responsible for the care of a client who is two days post-reconstructive nasal surgery. Which task can be safely delegated to an unlicensed assistive personnel (UAP)? Observe for restlessness or changes in breathing patterns Ask the client if the medication for pain was effective Remind the client to report increased pain or changes in comfort Suggest that the client ask for pain medication every few hours
Remind the client to report increased pain or changes in comfort The person to whom the activity is delegated must be capable of performing it. Only the RN can assess and evaluate the client's level of pain or teach the client about pain management. However, it is within the role of the UAP to reinforce the nurse's teaching about pain management.
As a part of a 9-pound full-term newborn's assessment, the nurse performs a dextro-stick at one hour post birth. The serum glucose reading is 45 mg/dL. What action by the nurse is appropriate at this time? Check the pulse oximetry reading Notify the pediatrician Give oral glucose water Repeat the test in two hours
Repeat the test in two hours This blood sugar is within the normal range for a full-term newborn. Normal values for the premature infant are 20-60 mg/dL or 1.1-3.3 mmol/L, the neonate are 30-60 mg/dL or 1.7-3.3 mmol/L, and the infant are 40-90 mg/dL or 2.2-5.0 mmol/L. Critical values for the infant are 40 mg/dL and newborn are 30 and 300 mg/dL. Because an increased birth weight can be associated with a diagnosis of diabetes mellitus, repeated blood sugars will be drawn.
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? Temperature of 102 F (38.8 C) Blood pressure of 94/50 Respiratory rate of 32 Pulse rate of 98 beats per minute
Respiratory rate of 32 Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are sudden tachypnea, dyspnea and chest pain.
A parent brings a 3 month-old infant into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects which findings on the initial history and physical assessment? Diarrhea and poor skin turgor Restlessness and irritability Increased temperature and lethargy Increased sleeping and listlessness
Restlessness and irritability This infant could be experiencing gastroesophageal reflux or perhaps an allergic response to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy-based formula may be recommended when allergies to the proteins in cow's milk formulas are suspected. Protein hydrolysate formulas are available when babies have a milk or soy allergy. Reflux would be treated with an acid-reducing medication such as ranitidine and positioning with the head elevated after feeding and while sleeping to reduce symptoms causing esophageal irritation.
A client develops volume overload from an intravenous infusion that has infused too rapidly. What finding should the nurse expect when assessing the client? Flattened neck veins Hypoventilation Thready pulse S3 heart sound
S3 heart sound Auscultation of an S3 heart sound is an early sign of volume overload and heart failure because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.
A nurse is caring for clients over the age of 70. The nurse is aware that when giving medications to older clients, it is best to use what approach? Review the drug regimen yearly Do not stop a medication entirely Avoid drugs with side effects that impact cognition Start with the smallest effective dose or increase dose slowly if needed
Start with the smallest effective dose or increase dose slowly if needed Due to physiological changes in the older adult, as well as conditions such as dehydration, hyperthermia, immobility and liver disease, the metabolism of drugs may be altered to be decreased. As a result, drugs can accumulate to toxic levels and cause serious adverse reactions.
The nurse is providing information to a client with diarrhea. Which of the following food choices should the client be advised to avoid? Steel-cut oatmeal with nuts and dried fruit Tender, well-cooked meat Macaroni made from white or refined flour Pulp-free fruit juice
Steel-cut oatmeal with nuts and dried fruit Clients should drink plenty of water and limit foods and beverages that contain caffeine, sugar, lactose, fructose or sorbitol. High potassium foods are recommended, such as bananas, potatoes (without the skin) and fruit juices. Spicy or fried foods, raw vegetables, nuts, dried fruit, whole grains and highly processed or fatty meats should be avoided.
The nurse is caring for a client with total parenteral nutrition (TPN). What is the most important action on the part of a nurse? Monitor for cardiac arrhythmias Sterile technique for dressing change at IV site Record the number of stools per day Maintain strict intake and output records
Sterile technique for dressing change at IV site Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing infection at IV infusion site.
A nurse is caring for a client with a serum potassium of 3.2 mEq/L. The client is placed on a cardiac monitor and started on IV infusion of 40 mEq KCL in 1000 mL of 5% dextrose in water. Which ECG findings indicate that the infusion of potassium should be stopped? Prominent U waves Shortened PR interval Tall, peaked T waves Narrowed QRS complex
Tall, peaked T waves Tall, peaked T waves are a finding in hyperkalemia, and would necessitate a change in IV solution, to eliminate the potassium. If the potassium infusion were to continue it could cause worsening hyperkalemia and possible cardiac arrhythmias. The nurse should notify the health care provider of the ECG finding, and should request an order for a different IV solution without potassium. In addition, a stat serum potassium should be done to assess the severity of the hyperkalemia and to determine whether further intervention to reduce the potassium level is required. In conjunction with this, a serum creatinine should be checked to determine whether worsening renal function may have reduced potassium excretion, contributing to this new electrolyte abnormality.
The nurse is making rounds with the pediatrician on the postpartum unit. Which of the following newborns should the pediatrician see first? The term infant whose blood glucose is 50 mg/dL The newborn, delivered eight hours ago, whose clamped umbilical cord has two arteries and one vein The newborn with widely spaced cranial suture lines The newborn delivered sixteen hours ago, who has yet to pass the first meconium stool
The newborn with widely spaced cranial suture lines Part of the examination of a newborn is to palpate suture lines; they should be palpable and separated. In cases where there is molding present, they may overlap. If suture lines are widely spaced it may be an indication of hydrocephaly or growth restriction. All the other findings are within normal limits for newborns at term: they usually pass their first meconium stool within 12 to 24 hours after birth; normal blood glucose is 40-60 mg/dL (hypoglycemia is anything < 40 mg) and umbilical cords have two arteries and one vein (only one artery can be indicative of a renal anomaly in the newborn.)
The nurse receives a telephone order from the health care provider for acetaminophen (Tylenol) 1000 mg by mouth for a client's headache. What should the nurse add to the following order when documenting it in the chart? (Write the answer using lower case letters.) Acetaminophen (Tylenol) 1000 mg by mouth for headache, one time dose. ______________ Dr. Smith 10/1/2012 at 2:30 pm (1430) by N. Nurse, RN.
The words "telephone order" must be written out to differentiate it from a verbal order or one written by the health care provider directly in the chart. Abbreviations should not be used. The health care provider needs to countersign the order according to the facility policy.
The nurse receives an order to give a client iron (Iron Dextran) by deep injection. What is the purpose of using the deep injection route for this medication? To provide more even distribution of the drug To enhance absorption of the medication To prevent the drug from causing tissue irritation To ensure that the entire dose of medication is given
To prevent the drug from causing tissue irritation Deep injection (or Z-track technique) is used to prevent irritating or staining medications from being tracked through the tissue. The nurse should be sure to change the needle after drawing the medication into the syringe (if it's not prefilled). The nurse will use a 2- or 3-inch, 19- or 20-gauge needle and administer the iron into the dorsogluteal muscle, using Z-track technique. The nurse should not massage the site afterwards.
There is an order for flumazenil (Romazicon) 200 mcg IV push over 15 seconds to reverse the effects of anesthia. Flumazenil is available in vials labeled: 0.5 mg/5 mL. How many milliliters will the nurse administer? ____________ mL
Using dimensional analysis, identify the desired dose and place it in the numerator. 200 mcg X 5 mL/0.5 mg X 1 mg/1000 mcg = 1 x 5 x 1/0.5 x 5 = 5/2.5 = 2 or 2 mL IVP over 15 seconds.
The nurse is caring for two children who have had surgical repair of congenital heart defects. For which defect is it the highest priority to assess for findings of heart conduction disturbance? Ventricular septal defect Atrial septal defect Patent ductus arteriosus Aortic stenosis
Ventricular septal defect While assessments for conduction disturbance should be included following repair of any defect, it is a priority for ventricular septal defect. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His) is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications often include conduction disturbances.
A nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The priority action of the nurse should be which of these? Ensure that feeding solution is at room temperature Check that the feeding solution matches the dietary order Verify correct placement of the tube Aspirate abdominal contents to determine the residual
Verify correct placement of the tube Proper placement of the tube prevents aspiration. The other options are correct actions but this question asks for the priority action. The approach to use is to ask: What is the outcome if I do not do this action? The worst outcome is commonly associated with the priority action. In this case, it is aspiration for the correct answer.
A nurse experiences a needle stick with a used hypodermic needle. What action should the nurse perform immediately? Look up the policy on needle sticks Vigorously wash the affected area with soap and water Notify the supervisor and risk management Contact employee health services
Vigorously wash the affected area with soap and water The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be to notify the supervisor and risk management, look up the policy and then contact employee health services.
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). The nurse should teach the client to avoid which of these foods? Wine, beer, cheese, liver and chocolate Wine, apples, sour cream and beef steak Beer, cheese, beef and carrots Wine, citrus fruits, yogurt and broccoli
Wine, beer, cheese, liver and chocolate These foods are tyramine-rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.
