NCLEX 4

During the physical assessment, the nurse determines the need to perform the bulge test. Which statement, if made by the nurse, is BEST?

"Please lie down and extend your legs." (1) correct—bulge test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed

The 20-year-old client calls the outpatient clinic to schedule a first Papanicolaou smear. The nurse recommends which preparation to the client?

Avoid douching for 24 hours before the appointment.

At 2100, the nurse notes that the last client documentation was at 0900. The nurse on the previous shift did not complete or sign the documentation for that period of care. Which action by the nurse is correct?

Begin documenting on the line below the last entry in the nurses' notes, leaving no spaces.

The 2-day-old infant is in surgery for repair of spina bifida. The infant's parent expresses concern because the health care provider said the infant would be confined to a wheelchair. Which statement made by the nurse is best?

"Corrective surgery will not change your child's physical disability." spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele

The nurse plans care for a group of clients. Which client will the nurse assign to the LPN/LVN?

Client receiving oral antibiotics for cellulitis.

The oncology nurse is reassigned to the medical-surgical unit. The charge nurse for the medical-surgical unit assigns which clients to the oncology nurse? (Select all that apply.)

Client who is receiving total parenteral nutrition (TPN) following gastrectomy 48 hours ago. Client who requires QID dressing changes for treatment of a MRSA-positive stage 4 pressure injury.6.Client admitted 3 days ago who is prescribed IV antibiotics for treatment of pneumonia.

A client develops orthopnea, dyspnea, and basilar crackles. Which action is MOST appropriate for this client?

Decrease the IV fluids, and notify the health care provider. (2) correct—orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority

The client takes chlorpromazine. The client is instructed to notify the nurse immediately if which sign or symptom is experienced?

Difficulty urinating. is an anticholinergic reaction that may become a severe health problem unless treated

During the first 24 hours after parenteral nutrition (PN) therapy is started, the nurse should take which action?

Evaluate blood glucose levels.

The nurse performs a nutrition assessment on an adolescent female client. Which dietary recommendation does the nurse give to the client and parents?

High calcium.

After being admitted involuntarily to a mental health facility, a client with a history of assault calls the nurse a "racist bigot." Which action is the most appropriate for the nurse to make?

Leave the room after informing the client of returning in 30 minutes.

The nurse provides education to a client who is newly diagnosed with systemic lupus erythematosus (SLE). Which client statement indicates to the nurse a need for further instruction? (Select all that apply.)

"I will wear SPF 15 sunscreen when I am outside." "The rash on my face will go away in time."4."I may need to take a medication that will boost my immune system." 4) CORRECT - Treatment of SLE may include the use of immunosuppressive medications in order to prevent a systemic response to the illness.

A client is admitted with abdominal pain and nausea. The health care provider orders stool for guaiac times three days. The nurse asks the nursing assistive personnel (NAP) to obtain the stool specimen. Which statement, if made by the NAP, requires an intervention by the nurse?

"I'll get a couple of specimens this afternoon because the client is having loose stools." (3) correct—ordered to be collected over 3-day period

An adult client is admitted to an acute locked psychiatric unit one month prior to an election. The client requests the opportunity to vote in the upcoming election. Which response by the nurse is best?

"I'll make the appropriate arrangements for you to vote."

A client is prescribed phenazopyridine 200 mg three times a day by mouth. Which information will the nurse include when teaching the client about this medication?

"If your skin or sclera develops a yellowish tinge, call the health care provider. " 3) CORRECT— Yellowish discoloration of the skin or sclera indicates that the drug is accumulating in the body because of renal impairment. This finding should be reported to the health care provider. Phenazopyridine is a urinary tract analgesic.

Following total hip arthroplasty, an elderly client is ordered to begin ambulation with a walker. Which statement by the nurse is correct?

"Make sure rubber caps are in place on all four legs of the walker." "Have someone help you tie your shoes before you begin ambulating." "Always wear non skid footwear when you walk."

A nurse in the pediatric clinic discusses the potential of lead exposure with the parents of preschoolers. It is important for the nurse to follow up on which statement made by a parent?

"My spouse renovates old houses."

A client has a left ankle injury and is instructed to use crutches when ambulating for 4 weeks. The nurse is observing the novice nurse provide instructions to the client. Which instruction causes the nurse to intervene?

"Place the top of the crutches about 5 inches below your armpits." Should be 5 cm or 2 in.

The nurse in the critical care unit reviews postoperative care for a client after a supratentorial craniotomy. Which instruction is important for the nurse to communicate to the unlicensed assistive personnel (UAP)?

"Put an ice pack on the client's eyes and a cool compress on the forehead." 1) CORRECT— It is appropriate to delegate the application of heat or cold to a closed inflamed or painful area to the unlicensed assistive personnel (UAP). The client may have periorbital edema and burning after the surgery. Ice will cause vasoconstriction and decrease the edema. The cool compress is a comfort measure.

The nurse discusses immunizations with a client in the third trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.)

"Since you are not immune to rubella, you will get immunized after your baby is born. "2."If needed, you can get the tetanus vaccine while you are pregnant. " "While pregnant, you should receive the influenza vaccine during flu season. "

A client with a history of recurrent depression has been referred to another care facility to help the client transition back into the workplace. A person telephones and tells the nurse, "Hi! I am the social worker assigned to the client. I am calling to ask about the client's current mental state and to know who is visiting the client." The nurse has verified that the social worker actually is assigned to the client. Which response is appropriate for the nurse to make to the social worker?

"Thank you for calling. I see that you need some information, but I need to ask the client for written consent before I can release information to you." 1) CORRECT- The nurse's responsibility in maintaining the client's right to privacy is to make sure that the client's right to keep personal information from being disclosed to others is respected. Any information disclosed to providers involved in the client's care should be limited to the absolute necessity and not include nonessential data.

The client comes to the local outpatient clinic reporting dizziness and palpitations. The physical exam and laboratory results are normal. The client reports the family-owned company is on the verge of bankruptcy. Which response, if made by the nurse to the client, is BEST?

"When did you first notice these symptoms?"

A mother brings her 7-year-old daughter to the outpatient clinic for a routine check-up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that the child has gained 2.5 lb and grown 3 inches in the past year. Which of the following responses by the nurse is BEST?

"Your daughter's height and weight are within normal limits." (1) correct—between ages 6-12, children grow about 2 inches (5 cm)/year and gain 4.5-6.5 lb (2-3kg)/year; at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 inches (111.8-129.7 cm)

The client is admitted to the hospital with dry mucous membranes and decreased skin turgor. The client's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the health care provider to order which IV fluids?

0.45% NaCl. correct—hypotonic solution, shifts fluid into intracellular space to correct dehydration 0.9 is isotonic, not best with dehydration

The nurse provides care for a client after surgery. Which intervention does the nurse include in the client's plan of care?

Begin oral fluids when bowel sounds are present.

A school-age client with asthma reports feeling progressively worse. Which assessment finding causes the nurse the most concern?

Decreased breath sounds bilateral lung fields. 3) CORRECT— In asthma with a severe spasm or obstruction, breath sounds and crackles may become inaudible. This finding indicates the need for immediate intervention.

The nurse administers meperidine 25 mg IV to a client in labor. Which fetal heart rate (FHR) pattern does the nurse anticipate as a result of administering this medication?

Decreased variability. 4) CORRECT— Opioid medications, such as meperidine, cause decreased variability by depressing the fetal central nervous system (CNS), which causes FHR to decrease.

The nurse delegates tasks to the unlicensed assistive personnel (UAP). For which UAP action does the nurse intervene? (Select all that apply.)

Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy.3.Reports a decrease in a client's systolic blood pressure to the health care provider.5.Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.

A client is transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine appears cloudy and foul-smelling. Which nursing measure is MOST appropriate?

Encourage the client to increase fluid intake. (2) correct—increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine

A client receiving peritoneal dialysis for newly diagnosed renal failure experiences abdominal pain during the dialysate infusion. Which action is appropriate for the nurse to implement?

Explain that discomfort subsides after the first few exchanges.

The nurse in the prenatal clinic assesses a client at 38 weeks' gestation. The client reports an inability to get comfortable. Which statement by the nurse is appropriate?

Inform the client that low-heeled shoes might help back discomfort.

The nurse cares for the client with a marked depression of T cells. The nurse should take which action?

Remove any standing water left in containers or equipment. Providing masks for anyone entering the room is not protocol unless the client has an active pulmonary infection

The nurse cares for a client diagnosed with pneumonia. Which observation indicates a therapeutic response to the treatment?

Respirations at 20 with moderate amount of thin, white sputum, denies dyspnea. (3) correct—sputum characteristics indicate a decrease in the pneumonia; is supported by respiratory status

The nurse knows that which assessment is BEST to indicate relief from abdominal pain for a child who received morphine 1 hour ago?

Results from the incentive spirometer have improved. (4) correct—when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer

Which action, if performed by the nurse, is considered negligence?

The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide PO at 7:45 AM. (3) correct—delay in medication may cause difficulty in swallowing, might have difficulty taking medication

The home health nurse visits an older adult client with visual impairment who lives alone. Which observation does the nurse discuss with the client? (Select all that apply.)

Throw rugs cover the electronic and lamp cords that run across the floor.2.The client wears a floor-length robe.3.When entering the home, the client removes shoes but leaves on socks.5.Various items are placed on the stairs next to the wall.6.The client sleeps with a heating pad.

The client is placed on cephalexin monohydrate prophylactically after surgery. Which foods should the nurse encourage?

Yogurt. Acidophilus milk. (3) correct—this food will help maintain normal intestinal flora, which may be altered by the cephalexin

The nurse cares for the client after a radical mastectomy of the right breast. Upon return to the unit, which position is most appropriate for the nurse to assist the client into?

Position the client in semi-Fowler's position with the right arm elevated. 3) CORRECT — this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema

The OB client comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made. It is MOST important for the nurse to take which action?

Prepare the client for an immediate cesarean section. Cannot deliver vaginally

The nurse provides care to a client with a cast on the left leg. Which exercise will the nurse recommend to this client?

Quadriceps setting of the affected limb. 2) CORRECT— Quadriceps setting is an isometric exercise. It is performed by contracting the muscle without moving the joint. This exercise maintains muscle strength while the limb is in a cast.

The college student has a positive Mantoux test. The health center clinic nurse takes which action?

Refers the student to an appropriate center for further testing. will perform chest x-ray Not quite ready to notify public health dept. or place in isolation

The nurse notes that the fetal position of a client at 35 weeks' gestation is right occiput anterior (ROA). Which location will the nurse find the point of maximum intensity of the fetal heart tones?

Right occiput anterior (ROA) indicates that the presenting part is the vertex with fetal occiput on the mother's right side toward the front of the pelvis. Because the fetus is vertex, the fetal heart tones will be heard below the umbilicus.

The nurse notices the elderly client has a dry, parched mouth and tongue. The nurse takes which action?

Rinses the client's mouth with room-temperature tap water before and after meals.

The home care nurse provides care to a client with alcoholic cirrhosis. Which caregiver statement requires intervention by the nurse? (Select all that apply.)

"I will give the low dose aspirin with breakfast." 1) CORRECT — Bleeding esophageal varices are the most life-threatening complication of cirrhosis. The client should not receive even low dose aspirin regularly. "We often have to wake the client to eat meals." 4) CORRECT — Encephalopathy from cirrhosis is caused by increasing ammonia levels, and it causes changes in consciousness, including lethargy. This requires follow-up. "The client's appetite is not good, so I'm glad to see a weight gain." 6) CORRECT — Weight gain may be due to fluid retention and ascites, because it is clearly not from nutritional intake. This requires follow-up.

The nurse reviews antenatal testing results for several clients. Which result will prompt the nurse to notify the health care provider?

A client at 40 weeks gestation with a positive contraction stress test. 4) CORRECT- A positive contraction stress test is designated by late decelerations following at least 50% of the contractions. Late decelerations indicate uteroplacental insufficiency.

The nurse observes an unlicensed assistive personnel (UAP) provide care for clients. Which observation by the nurse requires an intervention?

A client diagnosed with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress. 4) CORRECT - This action is to be avoided by having the upper leg mildly flexed and resting on a pillow from groin to feet. A potential trouble area of the side-lying position is hip joints that are internally rotated, adducted, and unsupported.

A client who had abdominal surgery 4 months ago experiences bloating, vomiting, cramping, and abdominal pain. Which does the nurse suspect as the cause of the client's symptoms?

Adhesions.

The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?

Administer bromocriptine as prescribed. This is neuroleptic malignant syndrome - serious complication of antipsychotics 2) CORRECT- NMS is a life-threatening complication. The nurse needs to manage fluid balance, reduce client temperature, and monitor for complications. The nurse should discontinue antipsychotic medications and administer bromocriptine (a medication to counteract the effects of NMS) and dantrolene as prescribed.

The nurse performs discharge teaching for the client diagnosed with multiple sclerosis. It is MOST important for the nurse to include which instruction?

Ambulate as tolerated every day.2.Avoid overexposure to heat or cold.3.Perform stretching and strengthening exercises.4.Participate in social activities.

The nurse provides care for clients in the emergency department. Which client does the nurse see first?

An older adult client with one episode of fainting. 4) CORRECT — The fainting episode may be the result of an irregular cardiac rhythm or rate change, and this requires an immediate cardiac evaluation to prevent cardiac and respiratory arrest.

The nurse receives report on the client who had an extensive stroke and is aphasic with a do not resuscitate (DNR) prescription. Initial assessment reveals pulse is 102 beats/min, respirations 28 breaths/min, BP 82/42 mm Hg, temperature 96.7°F (35.9°C) orally, and O 2 saturation of 84% on 4 L/min oxygen by nasal cannula. Which actions will the nurse implement based on these data? (Select all that apply.)

Assess for advance directives.2.Contact the health care provider.3.Confirm the DNR prescription.4.Contact the family about impending death.5.Provide pain medication. Do not place in high fowlers after a stroke.

The nurse cares for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It is MOST important for the nurse to take which action?

Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger. (4) correct—as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion

The nurse provides care for a client preparing for discharge from the facility. Which action should the nurse take when the client states, "I haven't told anyone else but I don't have any place to go. I live under the highway bridge"? (Select all that apply.)

Collaborate with the unit discharge planner. Ask the client's permission to share the information with the unit's discharge planner. Do not ask why questions, focus on the here and now. Access to medications is important, but only one component and working with DC planner is better.

The nurse on the medical unit reviews laboratory results on four clients. Which result causes the nurse to notify the health care provider?

Digoxin level 2.5 ng/mL (3.2 nmol/L) for a client diagnosed with heart failure. 2) CORRECT - The normal therapeutic level of digoxin in the blood is between 0.5 and 2 ng/mL (0.6-2.6 nmol/L). The client with a digoxin level of 2.5 ng/mL (3.2 nmol/L) has digoxin toxicity, and this should be reported to the health care provider. Digoxin is a cardiac glycoside and a positive inotrope.

The nurse obtains a history on a middle-age adult client who has come in for a gynecological examination. The client shares with the nurse that having intercourse is painful. Which action does the nurse take first?

Explore the client's personal menstrual history. 1) CORRECT— The client is probably experiencing dyspareunia caused by perimenopause or menopause. The nurse should assess the client's menstrual status before determining the appropriate course of action.

The nurse observes a novice nurse perform postmortem care on a client who has just died. Which action by the novice nurse requires an intervention? (Select all that apply.)

Eyes are kept open.2.Dentures are removed.2) CORRECT- During postmortem care, dentures are left in place to maintain facial shape. This action would require an intervention by the nurse. 3.Arms are placed behind the head..5.IV infusion is maintained at 75 mL/hr.

The nurse admits a client diagnosed with alcohol withdrawal syndrome (AWS). The client ingested the last drink 4 days ago. The nurse anticipates the onset of which symptom?

Fever. Mild tremors are early symptom: 5-8 hours after last drink. Hallucinations and grand mal seizures in stage 2 - 24-72 hours after last drink. Fever associated with stage 3: 3-4 days after last drink. Addl symptoms: HTN, delirium, sweats and tremors.

The nurse provides care for an older adult client who requires bilateral eye patches. Which action is appropriate for the nurse to take with this client?

Frequently touch the client while speaking. 4) CORRECT— Nurses and other providers always speak to the client who is visually impaired when entering the room. This helps not to startle the client. Touching the client provides reassurance.

An older adult client with a diagnosis of urinary incontinence wears disposable undergarments and changes them infrequently. The client reports new perineal skin irritation. Which suggestion does the nurse make to address the irritation? (Select all that apply.)

Gently rinse the perineum area with warm water and pat dry several times a day. Apply a zinc oxide-based barrier cream to the perineal area during each brief or incontinence pad change. not place a portable toilet by the bed, because it doesn't address immediate report of skin irritation. Topical abx not needed yet.

The nurse counsels the mother of a school-age client who is diagnosed with laryngitis secondary to pharyngitis. Which intervention is appropriate for the nurse to suggest to the mother?

Give the child a paper and pencil to communicate.

An older adult male client has difficulty voiding. Which action does the nurse take to promote urinary elimination? (Select all that apply.)

Have the client stand when attempting to void. 1) CORRECT- Men should stand, if capable, when attempting to void. This action is appropriate when promoting urinary elimination. Teach the client to gently press on the pubic area when trying to void. Have the client drink at least 2 liters of fluid each day.

The nurse provides care for a client who has a chest tube connected to a disposable chest drainage system. Which action should the nurse implement in order to maintain the function of this system?

Keep water level in the water-seal chamber at the 2 cm mark.

A newly admitted client receives a lithium prescription for treatment of bipolar disorder. The client's serum lithium level is 1.7 mEq/L (1.7 mmol/L). Which action does the nurse take first?

Notify the health care provider. 3) CORRECT - The therapeutic range of lithium for initial management is 1 to 1.5 mEq/L (1 to 1.5 mmol/L). Toxic manifestations may occur at levels greater than 1.5 mEq/L (1.5 mmol/L), and the HCP should be notified. Observe for vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, and muscle twitching. The therapeutic range of lithium for maintenance is 0.8 to 1.2 mEq/L (0.8-1.2 mmol/L).

Following the removal of a brain tumor from a child, the nurse observes a colorless drainage on the dressing. Which action does the nurse take first?

Notify the health care provider. Could be CSF and this is bad/not to be expected

The labor and delivery nurse begins the admission procedure for a client who is at 38 weeks' gestation and is diagnosed with gestational hypertension. Which is the priority nursing action?

Obtain the vital signs. (2) correct—assessment; important to do a baseline assessment in order to successfully evaluate the treatment ASSESS FIRST

The client is diagnosed with heart failure. The nurse receives a new prescription to administer IV chlorothiazide. The nurse questions this prescription based on which laboratory value? (Select all that apply.)

Serum sodium = 128 mEq/L (128.0 mmol/L). Thiazide diuretics are prone to produce hyponatremia because they increase sodium excretion without affecting the kidney's ability to concentrate urine. This client's sodium is decreased. Therefore, the nurse questions this prescription. 2.Serum calcium = 12 mg/dL (3 mmol/L). Thiazide diuretics decrease excretion of calcium. This client's calcium level is elevated. Therefore, the nurse questions this prescription. Serum pH = 7.48. Thiazide and loop diuretics produce metabolic alkalosis because of urinary loss of hydrogen. Therefore, the nurse questions this prescription.

The nurse teaches a community education program about cancer prevention for both men and women. Which strategy is most important for the nurse to include in the teaching?

Smoking cessation. MORE than protection from UV light

The preoperative nurse plans to have the client sign a consent form for today's surgery. After looking at the client's record, the nurse realizes that the client received midazolam 15 minutes ago. Which is the appropriate action for the nurse to take?

Tell the health care provider that the client is unable to give consent at this time.

Three staff members prepare to turn and reposition a client recovering from a laminectomy. Which observation by the nurse requires intervention?

The legs of the client are straight and in contact with each other. 4) CORRECT— This observation requires an intervention from the nurse. A pillow should be placed longitudinally between the client's legs to prevent hip and lower leg adduction and spinal torque when turning.

The nurse performs screening at the local senior citizen facility. The nurse is most concerned if which finding is observed?

The nurse auscultates an S3 ventricular gallop on the 78-year-old client. entricular gallop is the earliest sign of heart failure

When preparing discharge plans for a client being treated for syphilis, it is MOST important for the community health nurse to include which information?

The practice of safe sex. (2) correct—practice of safe sex, e.g., use of condoms, is primary prevention for transmission of sexually transmitted infections

Which finding indicates to the nurse that the client's Salem sump tube (nasogastric) is functioning effectively?

The presence of a hissing sound from the blue lumen tube. (3) correct—hissing sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa

The nurse supervises the care of a client who just had a short leg cast applied. Which observations demonstrate to the nurse that care is appropriate? (Select all that apply.)

The staff handles the cast using the palms of the hands.3.The affected limb is elevated to the level of the heart.4.The nurse compares the toes of the casted leg with the opposite leg.5.The staff places a fan in the client's room. Also need to turn the client every 2 hours and leave the cast uncovered

The nurse cares for the client after an ileostomy. The nurse is most concerned if which observation is made?

The stoma appears to be tight, and there is a decreased amount of stool.

The nursing team consists of an RN, two LPN/LVNs, and a nursing assistive personnel. The RN cares for which client?

The teenager with a head injury and a Glasgow coma scale of 5 requiring personal care.

An adult multipara client is seen in the prenatal clinic. The nurse notes the client is in the fifth month of pregnancy and has a weight gain so far of 14 lb (6.36 kg). The history indicates the client was of average height and weight prenatally. The nurse knows which statement is most likely true?

The weight gain is appropriate, and the present diet should be continued. 3) CORRECT — weight gain 2-5 lb (0.9-2.27 kg) first trimester, 0.66-1.1 lb (0.3-0.5 kg) weekly in second and third trimester

The client is admitted with a diagnosis of a fractured right hip. The health care provider writes an order for Buck's traction. Which nursing action is most important?

Turn the client every 2 hours to the unaffected side. immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side

The charge nurse in the emergency department receives notification that two victims of a violent gang-related shooting are en route. Which aspect of the hospital's safety plan is priority for the nurse to review with staff before the clients arrive? (Select all that apply.)

Visitor identification badges must be worn at all times. 3) CORRECT- Since the clients were involved in a violent gang-related incident, it is important to closely monitor visitors at the hospital. By ensuring no visitors are allowed to enter the department without proper hospital identification, the potential for hazardous situations to arise is decreased. Review all hidden panic buttons to alert security of an emergency.

The nurse prepares teaching material for an older adult client diagnosed with osteoporosis. Which recommendation will the nurse emphasize when teaching this client?

Walk for 30 minutes three times a week.

During the nursing history interview, the preschooler's parent reports the child has frequent bouts of gastroenteritis. Which question is most important for the nurse to ask?

"Does the child attend a day care center?" environments with increased numbers of children (day care centers) are more likely to promote infections due to close living conditions and increased likelihood of disease transmission

A 3-year-old boy was shown to have delays on the Denver Development Screening Test (DDST). The mother asks the nurse, "Does this mean my child is going to be slow?" Which response by the nurse is BEST?

"What are your thoughts about how your child performed on the test?" (3) correct—open ended, encourages discussion

The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOST concerned if a family member makes which statement?

"A family member will closely watch the monitor all the time." (4) correct—indicates a feeling that monitor may not let them know if their infant stops breathing

When caring for a client postpartum, the nurse provides education regarding proper perineal care. Which client statement indicates that additional teaching is needed?

"I will change my peri-pads when soiled." 2) CORRECT— This statement indicates that the client needs additional teaching. Peri-pads should be changed every time the client uses the bathroom regardless if the peri-pad is soiled or not. The client should not place a used peri-pad against a clean perineum.

An older adult client diagnosed with type 1 diabetes mellitus (DM) relocates to a nursing facility, but neglects to bring all prescribed medication. Which response is the best for the nurse to make when the client says the missing medication relieves burning and stinging in the feet and legs?

"I will contact your health care provider to find out what medication you are taking." DO NOT ask the patient to describe the drug. Not safe.

The nurse provides care for a client diagnosed with atherosclerosis. Which client statements about clopidogrel require follow-up by the nurse? (Select all that apply.)

"This medication may cause my blood pressure to be low. "2."I play racquetball three times each week for exercise. "3."I need to go back to the health care provider next year. " 1) CORRECT— Adverse effects of clopidogrel include hypertension, so this statement requires the nurse to follow up. 2) CORRECT— Because clopidogrel increases the client 's risk of bleeding, contact sports such as racquetball should be avoided. The nurse will discuss safe exercise choices with the client. 3) CORRECT— Clients taking clopidogrel will need regular medical supervision and periodic blood tests. The nurse should discuss follow-up care with the client.

The nurse teaches a group of older adults at an extended care facility about the correct way to use assistive devices. Which statement by a client indicates that further teaching is needed? (Select all that apply.)

"When I use my cane, I will put it in my right hand because my right leg is still weak from my stroke." - Should go on side of good leg "To keep me balanced when I use my crutches, the bottom of each crutch should be touching the outside of each foot." Should not go along with feet. "If I need to stop and rest when I use my crutches, I put the tops of the crutches under my armpits to support my weight." - This is not good for circulation. NOT: "My walker works best when I lift and move it forward about 8 to 10 inches with each step." this is how he is supposed to do it - lift, not push

The client has surgery for cancer of the colon, and a colostomy is established. Before discharge, the client tells the nurse that swimming will no longer be allowed. Which response by the nurse is correct?

"You may resume all previous activities."

A client with type 1 diabetes mellitus (DM) who delivered a healthy newborn asks how insulin needs will change with breastfeeding. Which response by the nurse is appropriate?

"You will have a decrease in your insulin dosage due to hormonal changes after delivery." 4) CORRECT - Insulin needs should decline rapidly after the delivery of the placenta and abrupt cessation of placental hormones. Blood glucose levels should be monitored at least four times daily so that the insulin dose can be adjusted to meet individual needs. Women with type 1 DM usually return to their pre-pregnancy insulin dosages.

The nurse prepares the client for a lumbar puncture. It is important that the nurse makes which statement?

"You will remain flat in bed for eight hours after the test." "You may feel discomfort in your leg when the needle is inserted." "You can have analgesics after the procedure if you have a headache."

A parent brings a 10-month-old child to the health clinic. The parent asks the nurse when the child will be ready to begin toilet training. Which response by the nurse is accurate?

"Your child should be ready in another 8 to 12 months."

The nurse prepares to change the dressing on the wound of a preschool-aged client. After explaining the procedure to the client, the client begins to cry and refuses to have the dressing changed. Which response by the nurse is best?

"Your mom is going to be here with you." 3) CORRECT - Parents offer the preschool-aged client comfort and security, and reduce the client's anxiety.

The nurse provides care for a client diagnosed with postural hypotension. The nurse includes which intervention in the client 's plan of care? (Select all that apply.)

1) CORRECT — Hypotension can cause generalized weakness. The client should implement energy conservation techniques to prevent excessive exertion and an increase in symptoms. 2) CORRECT — Increased fluid intake may correct hypotension related to decreased fluid volume.5) CORRECT — A slow rise to the standing position may prevent falls.

A pediatric client presents with flushed skin, generalized itching, nausea, wheezes, and inspiratory stridor after being stung by a bee. Which medication prescriptions will the nurse expect to implement for this client? (Select all that apply.)

1) CORRECT — The nurse expects to implement this medication prescription. Intramuscular (IM) epinephrine is appropriate for anaphylactic shock because it causes peripheral vasoconstriction and bronchodilation. 2) CORRECT — The nurse expects to implement this medication prescription. Intravenous (IV) diphenhydramine is appropriate for anaphylactic shock because it blocks histamine release. 4) CORRECT — The nurse expects to implement this medication prescription. Intravenous (IV) methylprednisolone is appropriate for anaphylactic shock because it treats inflammation and elevates blood pressure if needed. 5) CORRECT — The nurse expects to implement this medication prescription. A nebulized albuterol treatment is appropriate for anaphylactic shock because it opens the airways and promotes oxygenation.

The nurse in the long-term care facility provides care for clients during an outbreak of Legionnaire disease. The nurse recognizes that which client is most at risk to develop the disease?

A 65-year-old client diagnosed with end-stage kidney disease. Clients diagnosed with Legionnaire disease develop pneumonia caused by Legionella pneumophila. Risk factors include advanced age (50 years or greater), end-stage kidney disease, immunosuppression, diabetes, smoking, and pulmonary disease. 4) CORRECT — The client has two risk factors: advanced age and end-stage kidney disease. This client is at highest risk of developing the disease.

The nurse makes a prenatal visit to the home of a client who is pregnant with a first child. Which observation would be of most concern to the nurse?

A cat is sleeping peacefully on the windowsill. 1) CORRECT — A cat presents a toxoplasmosis risk to the pregnant client and her unborn fetus. Toxoplasmosis is a parasitic disease transmitted in the feces of cats that have eaten infected mice and animals. Preventive measures include handwashing after touching cats and having the litter box changed daily (it takes about 1 to 5 days for the cat's feces to become infectious) by someone other than the pregnant person. Prevent cats from eating raw meat or wild animals. Wear gloves when gardening, and do not garden in areas frequented by cats. Avoid undercooked meat and contact with stray animals. THE CAT IS A BIGGER PRIORITY THAN RUGS BEING FALL RISK

Some events observed by a nurse must be reported to the supervisor in an effort to improve quality and performance. Which client situation is a serious reportable event (SRE)? (Select all that apply.)

A client attempts suicide and goes into hypovolemic shock. An older adult client develops a stage 3 pressure injury.4.A client has a stroke due to an air embolism in a central line.5.A client diagnosed with cancer dies during surgery. ONLY a fall that results in a serious injury is a serious reportable event.

The nurse receives four new admissions. Which client is placed in a private room?

A client diagnosed with disseminated herpes zoster. 4) CORRECT— Disseminated herpes zoster requires airborne and contact precautions. These transmission precautions are observed until the lesions are dry and crusted. This client is not cohorted with other clients.

The nurse plans discharge for a group of clients. The nurse identifies which clients require a referral for home care?

A newly diagnosed diabetic client who has a vision impairment. (2) correct—Follow up on medication administration and ability for self care at home. A client with congestive heart failure who underwent diuresis in the hospital. (4) correct—assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia An elderly client with a new right hip replacement who lives with a daughter. (5) correct—the client will need assessment in the home for self care; family can help but not full care.

The triage nurse prioritizes clients for evaluation. Which client does the nurse determine needs to be seen first?

A woman at 6 weeks' gestation and who reports left lower quadrant abdominal pain and vaginal spotting. 1) CORRECT - The symptoms are indicative of an ectopic pregnancy, which may result in death if allowed to progress.

The nurse provides care to a client who is admitted to the emergency department (ED) with a serum glucose level of 32 mg/dL (1.8 mmol/L). The client is drowsy and has cold, clammy skin. The nurse anticipates implementation of which priority intervention?

Administer glucagon IM.

A client reports stabbing facial pain and twitching facial muscles a week after having a toothache. The client is diagnosed with trigeminal neuralgia. Which nursing actions does the nurse implement when providing care to this client? (Select all that apply.)

Administer oral carbamazepine as prescribed. Teach to chew on opposite side of mouth. Do NOT teach isometric exercises, (for bells palsy) administer IV hydrocortisone (for bells palsy), or perform facial massage.

The nurse assigns a client who is receiving oxygen via a Venturi mask to the unlicensed assistive personnel (UAP). Which task can be delegated by the nurse to the UAP? (Select all that apply.)

Attach the client to the finger pulse oximeter.2.Take the client's vital signs and record the results.3.Report changes in the oxygen saturation to the nurse.4.Place the call button within reach of the client.

The nurse provides care for a client prescribed negative-pressure wound therapy for a wound on the left lower extremity. Which is the most important action for the nurse to take prior to initiation of the therapy?

Check serum protein levels. 1) CORRECT— Protein is essential for wound healing. If the client's protein level is low, wound healing will be impaired and the negative-pressure wound therapy may not be helpful.

The nurse cares for the elderly client diagnosed with type 1 diabetes. The client is scheduled for cataract surgery under general anesthesia at 09:00. The client usually receives 30 units of intermediate-acting insulin and 10 units of short-acting insulin each morning at 07:00. At 07:00 the morning of surgery, the nurse expects to take which action?

Hold the morning dose of intermediate-acting insulin and short-acting insulin and monitor the blood glucose. usually use sliding scale with regular insulin based on blood glucose readings

The nurse provides care for a malnourished client who is diagnosed with anorexia nervosa. Which abnormality does the nurse expect the client's laboratory tests to reveal?

Hypophosphatemia. Hypophosphatemia, which refers to a decreased phosphate concentration in the blood, is often present in clients with anorexia nervosa who are malnourished.

The nurse provides care for a client with a burn wound on the left lower leg and ankle. The client has a new autograft and grafting to the wound. Which prescription does the nurse anticipate for this client?

Immobilization of the left leg. 3) CORRECT— Autografts on the lower extremities are usually elevated and immobilized following surgery for 3 to 7 days.

The nurse coordinates care on the medical-surgical unit. Which client indicators, if assigned by the nurse to the LPN/LVN, suggest professional negligence? (Select all that apply.)

Client with hemoglobin 6 g/dL (60 g/L).3.Client with blood urea nitrogen 80 mg/dL (28.56 mmol/L). 6) CORRECT — This client has severe thrombocytopenia and will likely require platelet transfusions and close observation for bleeding by the nurse. The normal platelet count is 150,000-450,000/mm 3 (150-450×10 9/L)

A client has a chest tube inserted for treatment of a hemothorax. Which finding indicates to the nurse that there is a problem with the effective functioning of the chest tube?

Constant bubbling is observed in the water seal chamber. (2) correct—would indicate an air leak, would not allow negative pressure to be re-established and would hinder complete resolution of the pneumothorax

A client receives heparin via continuous IV infusion for management of venous thromboembolism (VTE). The partial thromboplastin time (PTT) is 1.5 times greater than normal. Which action by the nurse is MOST appropriate?

Continue to monitor the client. (4) correct—expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage

A client diagnosed with a urinary tract infection suddenly reports extreme body pain and shivering. The client's vital signs are: BP 90/60 mm Hg, P 130 beats/minute, R 26 breaths/minute, T 102.2°F (39°C). Which action does the nurse take first?

Coordinate with the lab to obtain a serum lactate test.

The nurse cares for the client with a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the client in respiratory distress. Which action does the nurse take first?

Cuts the balloon ports and removes the tube. 3) CORRECT — scissors always secured at the bedside; remove tube if observing signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon

Several hours after an oxytocin infusion is started, a client 's contractions are sustained over 2 minutes. Which nursing action is most important for the nurse to take?

Discontinue the IV oxytocin. NOT just decrease it.

The 5-year-old child is scheduled for a lumbar puncture (LP). Which nursing action best prepares the child for the procedure?

Do a mock run-through of the procedure. excellent method to use with a child because it incorporates actually "feeling" many aspects of the procedure as they are explained

The client is newly diagnosed with type 1 diabetes. The nurse instructs the client to take which action if symptoms of hypoglycemia occur?

Drink 1/2 cup fruit juice followed by peanut butter crackers. NOT a candy bar. too concentrated and will cause hyperglycemia.

The client reports pain after an appendectomy. After administering an analgesic, the nurse takes which action?

Elevates the head of the bed 30-45°.

The nurse provides care for a client in the second trimester of pregnancy. Which assessment finding does the nurse attribute to the normal blood volume increase in pregnancy?

Elevation in client's heart rate of 10 to 15 beats.

The client tested positive for the tuberculosis antibody and was placed on isoniazid 4 weeks ago. The nurse is most concerned if which observation is made?

Fatigue and dark urine. initial indications of hepatic dysfunction

The RN cares for the client just admitted after sustaining a second-degree thermal injury to the right arm. Which observation is MOST important to report to the health care provider?

Gastric pH less than 5.0. At risk for developing ulver Elevated hematocrit is an expected finding in burn wound.

The nurse performs a routine IV tubing change on a client with a central line. Fifteen minutes later, the nurse re-enters the client's room to find the client cyanotic, short of breath, and reporting of pain. The client's vital signs are BP 84/62, pulse 112, respirations 18. What is the FIRSTaction the nurse should take?

Lower the head of the bed and place the client on the left side. (2) correct—air will rise to right atrium, minimizes chance of air bubbles entering pulmonary circulation

Which action, if performed by the nurse, is considered negligence?

Massage lotion on the abdomen of a 3-year-old diagnosed with Wilms' tumor. (2) correct—manipulation of mass may cause dissemination of cancer cells

The nurse provides care for a client taking disulfiram. Which medication is important for the nurse to instruct the client to avoid?

Over-the-counter cough syrup. 1) CORRECT - Intake of any form of alcohol with disulfiram will cause a severe reaction, including flushed skin, pounding headache, tachycardia, chest pain, shortness of breath, blurred vision, and hypotension. Most over-the-counter cough/cold preparations contain varying levels of alcohol and will precipitate this reaction.

The nurse cares for the client in the emergency room. Before administering calcium gluconate 10% 500 mg IV stat, which assessment should the nurse complete FIRST?

Patency of the vein. (3) correct—if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn

The charge nurse observes a novice nurse caring for a client with right-sided weakness following a stroke. Which action by the novice nurse will require the charge nurse to intervene?

Performing carotid sinus massage. 4) CORRECT- This is contraindicated in clients with stroke as it can increase the risk of cerebrovascular accident.

The nurse provides care to a client who underwent abdominal surgery. Assessment of the client's abdominal incision reveals that three staples have dislodged and the wound edges are separating. The nurse will implement which action? (Select all that apply.)

Place a sterile saline dressing over the wound. Place the client in a semi-Fowler's position with knees bent. do NOT attempt to secure the edges of the wound or apply abdominal binder

The nurse provides care to a client from Somalia who is scheduled to have a basal cell carcinoma on the face excised. Which assessment is most important for the nurse to make?

Radiation treatment for acne. 3) CORRECT-Research has demonstrated that clients similar to this one, who had previous exposure to radiation treatment for acne, are developing basal cell carcinoma.

A client undergoes admission from the recovery room with an intravenous fluid infusing at 100 mL/hour. There are 900 mL left in the bag. One hour later, the client has received 850 mL. The nurse is most concerned by which assessment finding?

Rales and tachycardia. 4) CORRECT - Rales indicate fluid in the lungs and tachycardia indicates cardiovascular fluid overload. These would both be associated with a sudden fluid overload.

The nurse prepares to administer hydroxyzine to a client. For which reason does the nurse use the Z-track method when administering this medication?

Reduces irritation to the subcutaneous and skin tissues. 3) CORRECT - The Z-track method is a variation of the standard intramuscular technique for administering medications that are highly irritating to subcutaneous and skin tissues.

The nurse supervises the staff caring for clients on the medical-surgical unit. The nurse observes the novice nurse enter a client's room wearing gloves and a mask. The nurse determines the precautions are correct if the novice nurse is caring for which client?

The teenager diagnosed with rubella (German measles). 4) CORRECT - Droplet precautions are used for organisms that can be transmitted by face-to-face contact, such as rubella (German measles). The door, however, may remain open.

The nurses on a medical-surgical unit hold a meeting to review data collected over the past 6 months. The data relate to the effectiveness of a new intervention that was implemented on the unit to decrease client falls. Which objective best describes the purpose of this meeting?

To discuss a quality improvement issue. 3) CORRECT- The purpose of this meeting is to discuss a quality improvement issue. Nurses are reviewing the collected data to evaluate the long-term (6 months) effectiveness of an intervention to decrease client falls. Safety is 2) INCORRECT- The issue discussed during the meeting has some relationship to safety, but the primary focus of the collected data is quality improvement over time rather than a specific safety issue.

The nurse assesses a client during the client's first prenatal visit. The nurse determines that the client is at 6 weeks' gestation. The nurse identifies which finding as a probable sign of pregnancy?

Uterine enlargement. 1) INCORRECT— Amenorrhea is a presumptive sign of pregnancy. Presumptive signs are felt by the woman, such as nausea/vomiting, breast sensitivity, fatigue, and quickening. 2) CORRECT— Probable signs are findings observed by the health care provider. Uterine enlargement, souffle and contractions, positive urine pregnancy test, Hegar sign, and Chadwick sign are all probable signs of pregnancy. 3) INCORRECT — Urinary frequency is a presumptive sign of pregnancy. Presumptive signs are felt by the client. 4) INCORRECT — Fetal heart tones auscultated by Doppler are a positive sign of pregnancy, along with palpation of fetal movement and a sonogram of the fetus.

The charge nurse reviews care for the client with internal radiation. The charge nurse intervenes if which actions are noted?

Visitors are limited to 5 hours per day with the client.all visitors are restricted with regard to the distance they should be from the client, with most text citing 3 hours per day is recommended A male caregiver is assigned to all care.2) CORRECT — this is an incorrect statement; caregivers are not to be assigned all care no matter their gender Lead-lined apron is worn for all care delivery.4) CORRECT — this is an incorrect statement; appropriate shielding (lead apron) is to be used when the nurse has to spend any length of time at a close distance, but not for routine care

The client receives digoxin 0.25 mg PO qd and furosemide 40 mg PO bid. The client calls the health care provider (HCP) reporting mild diarrhea. The HCP prescribes bismuth subsalicylate 60 mg after each bowel movement for two days and instructs the client to call back if symptoms don't subside. The client asks the office nurse if there should be any changes to the medication schedule. The nurse should instruct the client to take which action?

Wait 1 hour before taking the scheduled medications if the bismuth subsalicylate is taken. (2) correct—bismuth subsalicylate absorbs PO meds, separate administration of other meds

The nurse on the burn unit orients new staff to infection control issues. Which measure is most important to emphasize for this particular type of unit?

Wash hands using a thorough and consistent approach. just like any other unit

The nurse observes a new graduate nurse palpating the uterine contractions of a primipara in active labor. Which action, if taken by the new graduate nurse, is appropriate?

The graduate nurse places one hand on the abdomen over the fundus, and with the fingertips, presses gently.

Which clients are appropriate for the charge nurse to assign to the LPN/LVN on a medical unit? (Select all that apply.)

The client with a colostomy whose appliance is leaking.3.The client with a seizure history who is receiving gabapentin.4.The client who needs elastic compression stockings applied.6.The client with diabetes mellitus who is due a dose of insulin.

The wound care nurse assesses a group of clients. The nurse determines that which client is receiving appropriate care? (Select all that apply.)

The client with a stage 3 pressure injury whose hydrocolloid dressing is changed weekly.4.The client with a spinal cord injury who has a non-blanching reddened area covered by a foam dressing.5.The client whose poorly healing leg wound is being treated with a negative-pressure wound vacuum system.

The nurse cares for the client hospitalized with an acute asthma attack. The nurse is most concerned if which finding is observed?

The client's pulse increases from 86 to 100 beats per minute. pulse increase is due to decrease in oxygenation of tissues

The office nurse observes a student nurse assess the blood flow in a client with peripheral arterial disease using a Doppler ultrasound device. The nurse intervenes when which action is observed?

The student nurse presses firmly while moving the probe proximal to distal. 2) CORRECT - Pressing snugly or excessively can compress the artery, obliterating the blood flow and the signal. Direction of movement, if done, should be distal to proximal.

The nurse obtains a history for the client with hyperthyroidism. Which assessment does the nurse report to the health care provider?

Anxiety with extreme nervousness.

The nurse cares for clients in the outpatient clinic. The young adult female arrives for help with weight loss. The client's weight is 257 pounds, and the client is 5'7". Which diet choice indicates the MOST appropriate choice for breakfast?

Applesauce, cream of wheat, toast. (1) correct—breakfast with some substance, won't leave client feeling hungry most of the morning Scrambled eggs, toast and bacon are too high of fat.

The client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 mL/h. It is most important for the nurse to take which action?

Apply thigh-high elastic hose to promote venous return.

The nurse assesses a client who underwent surgical repair of a hip fracture. The nurse recognizes which assessment finding as indicative of a potential complication due to immobility? (Select all that apply.)

Left lower leg edema.3.Crackles auscultated in the lung bases.4.Muscle atrophy. 5.Nonblanchable skin erythema.

The nurse reviews the prescription for hormone therapy for a client with prostate cancer. Which goal of treatment will the nurse identify as important when planning care for this client?

Limit the amount of circulating androgens. 4) CORRECT- Limiting the amount of circulating androgens is the desired outcome because prostate cells depend on androgen for cellular maintenance.

The nurse provides care for a client in the post-anesthesia care unit (PACU). Which assessment finding requires the nurse to contact the health care provider (HCP)? (Select all that apply.)

The client experiences coarse, crowing respirations.2.The client's respiratory rate is 10 breaths/min.3.The client is disoriented and has oliguria.4.The client is restless and shouting.5.The client's core temperature is 94.8ºF (34.89ºC). ALL OF THESE we are worried about oxygenation

The nursing assistive personnel comes to take the client by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck. Which observation, if made by the nurse, requires an intervention?

The client has a nitroglycerine patch on the right chest area. should be removed before the test; transdermal patch contains heat-conducting aluminized layer and burning of skin may occur

The nurse assesses a client who is diagnosed with hypoparathyroidism. Which data, if found in the client's medical history, are associated with the diagnosis of hypoparathyroidism? (Select all that apply.)

Carpal spasms.2.History of convulsions.5.Muscle irritability.

The nurse receives four new admissions. Which client is placed in a private room?

A client diagnosed with group A streptococcus cellulitis. 2) CORRECT— An integumentary infection caused by group A strep requires contact precautions until 24 hours after initiation of effective therapy. This type of bacteria can result in necrotizing fasciitis.

The nurse provides care for clients in a long-term care facility. A client is diagnosed with Legionnaire disease. Which action by the nurse is appropriate?

Ask for maintenance on the institution's hot water tank. 2) CORRECT— Legionnaire disease is caused by Legionella pneumophila, which is found in warm, stagnant water such as hot water tanks and is spread by the aerosolized route from the environmental source to the client. Maintenance on the hot water heater is required to eliminate the source.

The nurse provides care for a client on bed rest who must maintain immobilization of the right leg. Which nursing action is most important?

Assist the client to turn safely every 2 hours. 4) CORRECT— Turning the client at frequent intervals prevents skin breakdown caused by pressure, friction, or shearing forces. This is the most critical intervention for the nurse to employ to keep the client's skin healthy and to maintain the immobility of the right leg.

The professional development educator teaches novice nurses about the causes of systemic inflammatory response syndrome (SIRS). Which types of injury will the nurse include in the teaching? (Select all that apply.)

Burn injuries.2.Crush injuries.3.Major surgeries.4.Bowel ischemia. NOT viral: 5) INCORRECT - This infection causes microbial invasion, not mechanical trauma.

The nurse assesses a client's hearing by performing the Weber test. The nurse notes that the sound lateralizes to the client's right ear. Which interpretation does the nurse make?

Sensorineural hearing loss in the left ear.

A community experiences a prolonged heat wave. The emergency department has several clients admitted from a construction project. Which indications will alert the nurse to the diagnosis for heat stroke?

Hypotension, tachypnea, tachycardia. 2) CORRECT — A client will have a temperature of 105°F (40.6°C) or above with skin that is hot and dry. A client's behavior may be bizarre, with confusion or delirium, or the client may be comatose.

The nurse plans discharge instructions for a client taking atorvastatin. Which health promotion information does the nurse include when teaching this client?

Increase intake of fiber. 4) CORRECT - Increasing fiber in the diet can reduce cholesterol levels by up to 10%.

The nurse provides an albuterol nebulizer treatment to a client recovering from respiratory failure. Which finding does the nurse expect to observe after treatment? (Select all that apply.)

Increased productive cough. Reports of decreased anxiety.5 .Bilateral hand tremors.5) CORRECT— Tremors are an expected side effect of albuterol and are not concerning.

The home care nurse visits a client receiving levothyroxine sodium 0.1 mg PO daily. Which finding indicates to the nurse that the client is getting favorable results from the medication?

Increased urine output. (2) correct—medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted

During a home health visit, an older adult Asian American client reports nausea and anorexia since taking isoniazid for 4 months. Which action will the nurse take first?

Inspect the hard palate. We want to look for drug-induced hepatitis. 2) CORRECT - Due to biocultural skin variations, signs of early jaundice are best observed on the posterior hard palate in people of Asian descent. Even sclera may contain carotene pigments that mimic jaundice in Asian American clients.

An elderly client is oriented during the day but becomes disoriented during the evening. Which nursing action is MOSTappropriate?

Install nightlights in client's room and bathroom. SAFEty

The nurse cares for a client diagnosed with hyperthyroidism. Which action, if taken by the nurse, is BEST?

Instill artificial tears PRN. (2) correct—clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis

The nurse provides care to a client diagnosed with iron-deficiency anemia. Which findings does the nurse anticipate as characteristic of this disorder? (Select all that apply.)

May occur with removal of duodenum. 3.Associated with chronic blood loss. 4.Most common type of anemia.

The nurse assesses a client with a serum sodium level of 138 mEq/dL (138 mmol/L), potassium level of 3.8 mEq/dL (3.8 mmol/L) and calcium level of 7.8 mg/dL (1.95 mmol/L). For which client symptom does the nurse assess? ( Select all that apply.)

Muscle cramps. 1) CORRECT — The client is experiencing hypocalcemia. Muscle cramps are associated with hypocalcemia. Serum calcium levels should be 8.2 to 10.2 mg/dL (2.05 to 2.55 mmol/L). 3) CORRECT — Chvostek sign is associated with hypocalcemia.

The nurse provides care for a client in the first trimester of pregnancy. The client experiences nausea. Which information does the nurse provide to the client? (Select all that apply.)

Nausea may be linked to the mother 's acceptance of the pregnancy.2.Nausea should diminish by the 14th week of pregnancy.3.Eating a dry carbohydrate immediately upon arising is recommended.5.Avoid fried, spicy, and greasy foods.

The nurse assesses a client who is prescribed lithium. Which finding indicates to the nurse that the client is experiencing early toxicity?

Nausea, vomiting, diarrhea.

The nurse instructs a client recovering from a right above-the-knee amputation (AKA). Which information does the nurse include in the client's teaching plan? (Select all that apply.)

Phantom limb pain is common after extremity amputation.3.Maintain the prone position several times daily.3) CORRECT - The prone position helps prevent contractures when recovering from an AKA. Anti-seizure medications may help with phantom limb pain.

The nurse provides care to a middle-age adult client who is hospitalized following a cerebrovascular accident (CVA). Which information in the client's history does the nurse recognize as being a risk factor for experiencing a CVA? (Select all that apply.)

Pheochromocytoma. 2) CORRECT - A pheochromocytoma is a benign (noncancerous) tumor that develops in one or both adrenal glands. Hormones released by the pheochromocytoma cause hypertension, which is a risk factor for CVA. 3.Routine use of ibuprofen. Diabetes mellitus.

A client is brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating. Which action should the nurse take FIRST?

Place the client in a quiet, darkened room. (3) correct—sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury

The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.)

Place tissue on stoma when changing the appliance.4.Cut the skin barrier 1/8 inch larger than the stoma.5.Empty the pouch of stool before removing the appliance.6.Check stoma for color, size, and shape. The client needs to avoid using moisturizing soap to clean the skin around the stoma, for it will interfere with the adhesive of the skin barrier.

The nurse assesses a client with diabetes insipidus. Which symptom will the nurse expect to find that is consistent with the diagnosis?

Polyuria.

The client diagnosed with lung cancer undergoes a pneumonectomy. In the immediate postoperative period, which assessment is MOST important?

Position of the trachea in the sternal notch. (2) correct—position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area

The nurse provides care for clients on the medical and surgical unit. Which observation requires intervention by the nurse?

The LPN/LVN repositions a client in Buck traction by first removing the traction weights. 4) CORRECT- Skeletal traction weights should never be removed without a health care provider prescription to do so, including when repositioning the client. Such an action would be painful for the client and would interrupt the line of pull.

After insertion of a central venous catheter (CVC), a client suddenly starts coughing. The nurse observes that the client is pale and dyspneic, and has tachycardia. Which action does the nurse take first?

Turn the client to the left side and lower the head of the bed. 1) CORRECT — The client's symptoms are consistent with an air embolism, which can occur with CVC insertion. Placing the client in the left lateral position prevents the air embolism from entering the right atrium and pulmonary artery, which would create a right ventricular outflow obstruction (air lock) and stop the heart. The client should be kept in this position for 20-30 minutes.

A 24-year-old woman at 30 weeks' gestation is seen in the outpatient clinic for a routine visit. The nurse is MOST concerned if the client makes which statement?

"During the day I seem to get hot flashes and chills." (1) correct—should be reported to the health care provider

The nurse follows up a community education session by asking clients to describe ways to reduce their cancer risk. Which client statement requires clarification by the nurse? (Select all that apply.)

"I should stop eating meat." "I should stop eating meat." 4."I will lose 20 pounds."4) CORRECT - The nurse should clarify that persons should strive for a normal weight. Each client will have different weight loss or maintenance goals, depending on age, gender, height, and weight. 5."I should not go outside on very sunny days."5) CORRECT - the nurse should clarify that clients may spend a moderate amount of time in the sun, as long as they use sunscreen and wear a protective hat and clothing. 6."I will avoid being around persons consuming alcohol."6) CORRECT - The nurse should clarify that clients should limit alcohol intake, but being around persons who drink is not a risk factor for cancer.

The nurse teaches the client being discharged on risperidone. Which client statements indicate the teaching has been successful?

1."I may gain weight when taking this medication."2."I should avoid extreme temperatures." "I will wear long sleeves when I am out in the sun."6."I will change positions slowly."

The nurse assists a graduate nurse with the care of a client whose blood glucose is 525 mg/dL (29.14 mmol/L), pH is 7.1, and serum bicarbonate level is 14 mEq/L (14 mmol/L) and has ketonuria. The nurse intervenes if the graduate nurse makes which statement? (Select all that apply.)

1."I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55 mmol/L)."2."The client's potassium level will increase as the blood glucose decreases."3."The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)." "I should check the client's blood glucose every 2 hours."

The nurse teaches a community education course for clients at risk of developing chronic kidney disease. Which characteristics are appropriate for the nurse to include as risk factors of chronic kidney disease? (Select all that apply.)

1.Age greater than 60 years. .Older African Americans. 4.Hypertension. 5.Diabetes mellitus.

The nurse works in the emergency department. A motor vehicle accident with multiple victims is called in on the radio. Which client will require the highest priority intervention? (Select all that apply.)

A client in the same vehicle as a victim who was deceased at the scene. 2) CORRECT- This client requires priority care and evaluation as they are at increased risk due to the mechanism of injury, which caused fatality. A client with second-degree burns to chest and hoarseness reporting a painful throat.

The nurse provides care for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red bleeding on the dressing. Which action is the first action for the nurse to take?

Apply gentle pressure to the penis.

The nurse reviews medical records of clients seen at the clinic. The nurse schedules cancer screenings for which clients based on their increased risk? (Select all that apply.)

The client who is a seasoned construction worker with red hair and freckles.3.The client who smoked a half-pack of cigarettes daily for 15 years.4.The middle-aged client whose parent was diagnosed with colorectal cancer.6.The overweight client who identifies as a "meat and potatoes person. " (colorectal cancer)

The client receives thrombolytic therapy. The health care provider orders morphine IM for pain. Before administering the injection, the nurse takes which action?

Verifies the order with the health care provider. implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the health care provider about the appropriateness of the order

The elderly adult is admitted to a medical unit with shortness of breath. The client is diagnosed with an upper respiratory infection (URI). The client is placed on droplet precautions. The nurse administers oral medications to the client. As the nurse leaves the room, the nurse takes which action?

Washes hands, removes the mask, and throws the trash in a container inside the room.

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour?

A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L). 4) CORRECT- This is the most stable client. Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L). Therefore, the current serum bilirubin level does not indicate the need for treatment.

The nurse overhears the unlicensed assistive personnel (UAP) discuss a client who is hospitalized under an alias after being injured while committing a crime. Which statement will the nurse make to the NAP? (Select all that apply.)

"We treat all of our clients the same, regardless of what they may have done."3."We can discuss the client's situation only with others involved in the care." "The discussion violates the client's confidentiality. Please stop the conversation immediately."

The nurse answers the phone on the psychiatric unit. The caller identifies himself as the spouse of a client and inquires about the client's condition. Which response by the nurse is MOST appropriate?

"Clients are not allowed access to this phone. Please call the number you were given." (2) correct— psychiatric client retains civil rights to communicate with outside world and have reasonable access to telephones; unless client opts out of the registry, their location may be given out with prearranged codes

The nurse plans to provide nutritional recommendations to the parent of a toddler. Which information does the nurse provide during this educational session? (Select all that apply.)

"Finger foods such as diced bananas and sliced avocado are excellent snacks for a toddler." "Grapes should be cut into small pieces for your child." NOT "Toddlers can be picky eaters, so offer snacks that are high in calories." 3) INCORRECT- While it is true that toddlers can be picky eaters, parents should offer nutritious snacks, not high-calorie snacks.

The nurse obtains a nursing history from a teenaged client. The client states that she drinks "lots" of fluids and still feels thirsty. It is MOST important for the nurse to ask which question?

"Has your weight recently changed?" (1) correct—excessive thirst and weight loss are two notable symptoms of type 1 diabetes

An adolescent client tells the nurse about being hungry and thirsty constantly, and that eating and drinking do not seem to help. It is most important for the nurse to ask which question?

"Have you had any weight changes in the past few months? " 1) CORRECT- Polydipsia and polyphasia, as well as polyuria, suggest type 1 diabetes mellitus (DM). It is important for the nurse to assess for weight loss, which is also an indicator of the condition. In children, the nurse may see fatigue and bedwetting.

An 8-year-old boy falls off the swings at school and hits his head. He is examined by the health care provider at an urgent care center. The client is diagnosed with a minor head injury, and sent home. Which statement, if made by the mother to the nurse, requires further teaching by the nurse?

"He will be well enough to play in his soccer game tomorrow." (4) correct—no strenuous activity for 48 hours

The home care nurse makes an initial visit to a client in the early stages of chronic obstructive pulmonary disease (COPD). The nurse plans to discuss the client's perception about the disease. Which response by the nurse is best?

"How has the COPD changed your life?" 4) CORRECT— Asking how COPD has changed the client's life allows the client to explain the impact of the disease. This information will help the nurse plan the client's care.

The nurse teaches the parent of an infant with developmental dysplasia of the hip (DDH) about home care. The infant will be discharged with a Pavlik harness. Which parent statement indicates further teaching is needed? (Select all that apply.)

"I can adjust the harness if it seems too tight or too loose." "It will be hard to keep my baby from moving around."5."I should put lotion under the harness straps so they won't irritate my baby's skin."

The nurse provides care for a toddler diagnosed with pneumonia who is in an oxygen tent. The mother indicates that the toddler's birthday is tomorrow and she would like to have a party. Which statement by the mother is important for the nurse to address?

"I found the neatest candles to put on the cake." 3) CORRECT — Oxygen is combustible and can cause a fire if it comes in contact with an open flame or electrical equipment. The nurse needs to inform the mother that the candles cannot be lighted.

A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique?

"I need to buy sterile gloves to redress this wound." NO - because not commonly ordered and don't need. The correct ones are: "I should wash my hands before redressing my wound." (2) correct—indicates understanding of asepsis, hallmark is hand washing "I should only use whatever my health care provider orders for the dressing change." "I should make sure someone looks at my wound every dressing change." "I will throw the dressing away in the kitchen garbage wrapped in my glove."

The home care nurse instructs a client diagnosed with Bell palsy. Which client statement indicates to the nurse that further teaching is necessary?

"I should avoid sudden movement when bending over." 2) CORRECT— This is not a necessary precaution unless a client has problems with increased intraocular pressure.

The nurse instructs a client receiving acyclovir. Which client statement indicates that teaching is effective?

"I should drink extra fluids while taking this medication." 2) CORRECT — Acyclovir may cause or contribute to renal failure. The client should drink additional fluids while taking the medication and report any decrease in urination to the health care provider.

The nurse instructs a client experiencing insomnia on sleep hygiene techniques. Which client statement indicates to the nurse that teaching is effective? (Select all that apply.)

"I should not look at my smartphone before going to sleep." "I should avoid caffeinated foods and beverages for at least 4 hours before bedtime."6."I should get out of bed if not sleepy and engage in a calm activity in another room until I feel drowsy."

A client developed diabetes insipidus following a craniotomy. The nurse provides discharge instructions for the client and spouse. Which statement, if made by the client, indicates to the nurse that further teaching is needed?

"I should weigh myself every day and drink less fluid if I gain more than 5 lb over a week." (3) correct—weight gain should be reported to health care provider, may need medication adjusted

The nurse cares for the client receiving atorvastatin. It is most important for the nurse to report which client statement to the health care provider?

"I take colchicine." concurrent use of colchicine and atorvastatin increases the risk of rhabdomyolysis

The nurse instructs the unlicensed assistive personnel (UAP) to put antiembolitic stockings on a client scheduled for surgery. Which statement by the UAP requires the nurse to intervene?

"I will apply the pair that I found in the supply room." 3) CORRECT - To ensure that the stockings fit properly, the UAP needs to measure the client first to determine the appropriate size for the client. This statement would require the nurse to intervene.

Alendronate sodium is prescribed for an older adult client. Which statement by the client to the nurse indicates that teaching about the medication is successful?

"I will sit and read a book for half an hour after I take it." 2) CORRECT — Alendronate is an oral biphosphate that inhibits bone resorption. It can be highly irritating to the gastrointestinal tract, particularly the esophagus. It can cause irritation and ulcerations or erosions. After taking the medication, the client should sit for at least 30 minutes in order to facilitate delivery to the stomach and prevent acid regurgitation and esophageal reflux.

The nurse observes a newly admitted client with a diagnosis of anxiety and panic attacks. The client is shaking, hyperventilating, and unable to breathe through cupped hands as instructed. Which statement by the nurse is therapeutic for the client at this time? (Select all that apply.)

"I will stay here with you for a while." Anything more is likely to irritate them. Can not follow instructions.

The nurse instructs a client with chronic pain on the use of a prescribed opioid medication. Which client statement indicates to the nurse that additional teaching is required? (Select all that apply.)

"I will wait 30 minutes after taking a dose before driving my car."3."I will limit the intake of fluids after taking a dose of medication."4."I will take an additional dose of the medication if pain is not relieved."5."I will limit my intake of fresh fruits and vegetables while taking this medication."

The nurse cares for the client in labor. Upon returning to the room, the nurse notes this pattern on the fetal monitor.2) CORRECT — persistent fetal bradycardia may indicate cord compression or separation of the placenta but always indicates fetal distress; left side reduces compression of vena cava and aorta

2) CORRECT — persistent fetal bradycardia may indicate cord compression or separation of the placenta but always indicates fetal distress; left side reduces compression of vena cava and aorta Turns the client on the left side, administers oxygen, and starts an IV.

The nurse cares for the client diagnosed with vasoocclusive crisis. The nurse instructs the client how to use patient-controlled analgesia (PCA). The nurse determines teaching is effective if the client makes which statement?

"If I start itching, I need to call you." Common reaction of narcotics used for PCA

The nurse cares for the client who delivered an 8 lb, 4 oz newborn. The newborn is diagnosed with talipes equinovarus. The client confides to the nurse, "I feel so bad that my baby is abnormal." Which response by the nurse is best?

"It's understandable that you feel this way, but there are treatments to correct your baby's problem." serial casting is used to treat infant

The school nurse teaches high school students about safe practices when it comes to loud noises and hearing. A student reports, "My parents are always yelling at me about my loud music and that I will go deaf. I tell them that when I get old, if I need a hearing aid, I will just get one. I already wear glasses." What is the best response by the nurse?

"Let me explain about the two main kinds of hearing loss."

The home health nurse makes a follow-up visit for the elderly client receiving isoniazid 200 mg every day for six months. The nurse is most concerned if the client makes which statement?

"My hands and feet tingle." (3) correct—may cause peripheral neuropathy indicated by tingling, may also see nausea

The nurse conducts preoperative teaching with the family of a client scheduled for a total laryngectomy. Which statement, if made by the family, indicates to the nurse a need for further teaching?

"My husband will require a feeding tube for several months." (2) correct—requires nutritional support for 10 days until wound heals, then gradually resumes oral intake "Dad is looking forward to learning how to laugh using tracheoesophageal puncture." (5) correct—will not be able to sing, whistle, or laugh using laryngeal communication

The nurse observes that two staff members have been in frequent conflict for the last several weeks. The nurse schedules a meeting with both staff members after observing them argue while putting a client back to bed. When meeting with the staff members, which statement by the nurse is most appropriate?

"Summarize what you hear the other person saying. The other person will then validate the summary." 4) CORRECT - Summarizing what was heard enhances communication. Each party is actively listening and hears the other person's perspective.

The nurse instructs the prenatal client about the importance of prenatal vitamins. It is MOST important for the nurse to include which instruction?

"Take prenatal vitamins with orange juice at bedtime." (1) correct—taking the vitamins with something acidic increases the absorption of iron; taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep

The nurse counsels a client diagnosed with tuberculosis (TB). The client asks the nurse what to do to prevent the spread of the disease. Which instruction from the nurse is most important?

"Take your medication as prescribed. " 1) CORRECT - Combination drug therapy is the most effective way to treat TB. With correct therapy, clients quickly become non-contagious. Failure to take medications correctly results in drug-resistant TB.

The nurse in the outpatient clinic receives a call from the parent of an adolescent diagnosed with infectious mononucleosis. The parent reports that the adolescent seems angry and depressed since the diagnosis. Which response by the nurse is most appropriate?

"Teens become frustrated because of feeling weak and fatigued."

The nurse teaches the spouse of a client about changing the dressing on a central venous catheter (CVC). The spouse asks, "What is that round foam disc for?" Which response by the nurse is accurate?

"The disc has anti-microbial properties to help prevent infection."

The nurse instructs the client being discharged on tranylcypromine sulfate. The nurse determines further teaching is needed if the client makes which statement?

"To celebrate, my wife and I are going out for pepperoni pizza and wine tonight." (1) correct—Tranylcypromine sulfate is an MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis

At an inpatient psychiatric unit, a client insists on staying in the room and repeatedly comments to the nurse, "Special agents are here. Maybe you are one." Which response, if made by the nurse, is BEST?

"You must feel afraid if you believe that, but there are no agents here."

A child with failure to thrive has a positive sweat test. Which change does the nurse anticipate in this client's plan of care?

Administer replacement enzymes. 1) CORRECT - A positive sweat test is a positive finding for cystic fibrosis. Treatment for cystic fibrosis includes the administration of replacement enzymes.

A client care team consists of a nurse, an LPN/LVN and an unlicensed assistive personnel (UAP). Which client will be assigned to the nurse?

Client diagnosed with toxic shock syndrome. 1) CORRECT - Toxic shock syndrome is caused by a Staphylococcus infection that causes vomiting, diarrhea, and shock. Early diagnosis and treatment are critical to avoid involvement with other organ systems. This client should be assigned to the nurse.

A nurse with postpartum care experience is reassigned to a medical-surgical care area. Which client will the charge nurse assign to the postpartum care nurse?

Client recovering from a sympathectomy as treatment for Raynaud disease. 2) CORRECT— Raynaud disease is a form of intermittent arteriolar vasoconstriction. A sympathectomy interrupts the sympathetic nerves. This client is stable and can be assigned to the nurse with postpartum care experience.

Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency Medical Treatment and Active Labor Act)? (Select all that apply.)

Client who reports dental pain is denied a medical screening. 2) CORRECT - Refusing to provide care violates EMTALA. All clients should receive medical screening examinations to determine whether emergency medical conditions exist. Client is transferred to another facility before attempts are made to stabilize client. 5) CORRECT- A client should not be transferred prior to stabilization or until the transferring hospital has provided medical treatments within its capability.

The clinic nurse calls the home of a client diagnosed with type 2 diabetes. The client had blood drawn earlier in the day, and the laboratory is reporting a blood glucose level of 475 mg/dL (26.36 mmol/L). The nurse instructs the client to go to the emergency department immediately, but the client responds, "I feel fine. That lab result must be a mistake." The nurse recognizes this response as associated with which coping or protective mechanism? (Select all that apply.)

Just denial, NOT rationalization because this serves to justify inappropriate behaviors like blaming others for something they did wrong.

The nurse provides care for a client diagnosed with myasthenia gravis. When completing a physical assessment, which clinical manifestations does the nurse expect to see? (Select all that apply.)

Muscle weakness. Ptosis.6.Diplopia.

The nurse provides care for a client diagnosed with paranoid schizophrenia. The clientrsquos spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?

NOT offering a sleep aid. Establish a trusting nurse-client relationship. 2) CORRECT — The client diagnosed with paranoid schizophrenia views the world as hostile and threatening, so the nurse's priority is promoting trust. Trust is promoted by establishing the nurse-client relationship.

The nurse assesses hypotension, tachycardia, and crackles in the lung bases of a client with an acute inferior wall myocardial infarction. Which action does the nurse take first?

Notify the health care provider. 2) CORRECT— The client exhibits signs of heart failure, a complication of acute myocardial infarction. The nurse should notify the health care provider of the change in the client's condition to prevent a delay in treatment.

A client is scheduled for a cardiac catheterization at 0800. The client's laboratory work was completed five days ago, and the results include K+ 3.0 mEq/L (3.0 mmol/L), Na+ 148 mEq/L (148 mmol/L), glucose 178 mg/dL (9.9mmol/L). The client reports of muscle weakness and cramps. Which action by the nurse is BEST?

Obtain stat K+ level. (3) correct—signs and symptoms are indicative of hypokalemia; stat serum K+ level is needed to confirm the K+ level prior to going for cardiac catheterization

The nurse assigns a client who is receiving a red blood cell transfusion to the unlicensed assistive personnel (UAP). Which actions can be delegated to the UAP? (Select all that apply.)

Obtain vital signs prior to the transfusion.2.Obtain blood products from the blood bank.4.Perform hourly rounding during the transfusion.5.Assist the client with toileting during the transfusion.

The nurse prepares a client to receive a prescribed dose of cisplatin. For which laboratory values will the nurse withhold providing this medication? (Select all that apply.)

Platelet count 60,000/mm3 (60000.00 x 109/L). 1) CORRECT — Cisplatin should be held if the platelet count is <100,000/mm3 (100,000.00 x 109/L). White blood cells 2,000/mm3 (2.00 ×109/L). 5) CORRECT — Cisplatin should be held if the white blood cell count is <4,000/mm3 (4.00 ×109/L). Creatinine 2.0 mg/dL (176.8 µmol/L).6) CORRECT — Cisplatin should be held if the creatinine level is greater than 1.5 mg/dL (132.60 µmol/L). The nurse needs to first stop and think of the reason why the client would be prescribed this medication. Cisplatin is a chemotherapeutic agent, used in the treatment of cancer. These types of medications can affect the red blood cells, white blood cells, platelets, and kidney function. Because of this, the laboratory values that reflect changes in platelets, white blood cells, and kidney function should be used to determine if it is safe to provide the medication to the client. Giving this medication could cause the client to develop an infection or begin to bleed.

A client is admitted to the emergency department (ED) with respiratory compromise. Which assessment finding does the nurse document as indicative of a pneumothorax?

Rapid respirations. NOT deep/hyperpnea.

The nurse plans care for the elderly client with dementia. Which action is the priority for the nurse?

Speak slowly in a face-to-face position.

The visiting nurse evaluates the progress of the client recently diagnosed with type 1 diabetes. As part of the treatment plan, the client receives intermediate-acting insulin 32 units and short-acting insulin 8 units each morning. Which client actions while preparing the morning insulin injection require an intervention by the nurse?

The client draws up 32 units of the intermediate-acting insulin first. 2) CORRECT — short-acting insulin is clear and drawn up first, only 8 units are ordered; intermediate-acting insulin is cloudy The client injects air into the intermediate-acting insulin vial then draws up 32 units. 3) CORRECT — after injecting air the client should withdraw the syringe to inject air into the other vial before withdrawing any insulin After drawing up the intermediate-acting insulin, the client injects air into the short-acting insulin vial. 5) CORRECT — air is injected before withdrawing the other insulin.

The nurse provides care to a client diagnosed with a hearing impairment. Which approach will the nurse use to facilitate communication with the client?

Use a normal tone. 1) CORRECT— Using a normal voice tone is important, as is talking directly to the client while facing the client and speaking clearly. talking louder will not help

A client who attends an outpatient clinic is taking chlorpromazine hydrochloride 100 mg tid. The client reports to the nurse that he is sleeping through the day. Which action by the nurse is MOST appropriate?

Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs. (2) correct—will reduce daytime sedation

The client admitted with metastatic cancer has received chemotherapy for three months. Lab values include RBC 3.8 million/mm3 (3.8 x 1012/L), WBC 3,000/mm3 (3.0 x 109/L), Hgb 9.3 g/dL (5.8 mmol/L), platelets 50,000/mm3 (50 x 109/L). Which symptoms does the nurse expect the client to exhibit?

BP 120/70 mm Hg, pulse 100 bpm, respirations 22 breaths per minute. 1) CORRECT — increased pulse and respirations are caused by decreased oxygenation of tissues; normal respiratory rate is 12 to 20 breaths per minute; normal pulse is 60 to 100 beats per minute

The nurse cares for a client receiving amphotericin B 1 mg in 250 ml of D5W IV over a 2-hour period. The nurse is MOST concerned if which is observed?

Blood pressure 90/60, reports fever and chills. (2) correct—monitor vital signs every 30 minutes

The nurse cares for the client following a coronary artery bypass graft (CABG). Which symptom does the nurse expect to see if the client is in the early stages of circulatory overload?

Change in the character of respirations. will see dyspnea, cough, edema, hemoptysis

The home care nurse visits the client reporting episodes of vomiting for 3 days. The client has a low-grade temperature and reports feeling lethargic. Which nursing action is most appropriate to evaluate for fluid volume deficit?

Determine client's weight and assess gain or loss. daily weight is the best way to evaluate for fluid volume deficit

The nurse cares for the client diagnosed with dementia in a long-term care facility. Which action by the nurse is best?

Direct conversation toward assisting the client to reminisce and talk about important past events in life. 4) CORRECT — geriatric client should be encouraged to talk about past life and important things in the past because the client has recent memory loss

The nurse performs the physical examination on the newborn. Which nursing assessments should be reported to the health care provider?

Edema of scalp normal due to delivery Head circumference of 40 cm.(1) correct—average circumference of the head for a neonate ranges from 32-36 cm; increase in size may indicate hydrocephaly or increased intracranial pressure

The postoperative client returns to the assigned room from the surgical recovery area. The client is sleeping, and the nurse notes the client is disoriented when aroused. Which nursing action is best?

Elevate the side rails until the client is fully awake.

A client diagnosed with a fracture of the left femur is placed in skin traction (Buck) with a 7-lb (3.2 kg) weight. The nurse notes the client keeps sliding down in bed. The nurse takes which action?

Elevates the head of bed and tilts the mattress, as in a slight Trendelenburg position.

The nurse cares for the client with deep partial thickness and full thickness burns. The client receives morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention. Which action, if taken by the nurse, is BEST?

Explore alternative pain management techniques.

The nurse performs discharge teaching for the client after abdominal surgery. The nurse determines that teaching is effective if the client chooses which foods for lunch?

Has high protein, high calories, and Vitamin C.

The RN cares for the 4-year-old diagnosed with epiglottitis. Which observation indicates to the nurse that the child is experiencing an early complication of hypoxemia?

Heart rate of 148 beats per minute (bpm).(1) correct—heart rate correlates with hypoxemia and is an early finding, along with restlessness 2.Bluish discoloration of the skin.(2) cyanosis, late sign 3.Bluish discoloration around the mouth.(3) circumoral cyanosis, late sign 4.Throwing toys and kicking the bed.(4) correct—Irritability is an early sign of hypoxemia. temper tantrum like behavior is not expected in a 4 year old. 5.Difficulty swallowing.(5) sign of epiglottitis not hypoxemia 6.Nasal flaring with activity.(6) correct—Nasal flaring is an early sign of hypoxemia.

The nurse cares for a client diagnosed with rheumatoid arthritis. The plan of care includes which interventions?

Heat ROM exercises Weight reduction NOT a soft mattress - want firm to keep joints in alignment

The nurse cares for the client diagnosed with hyperparathyroidism. Which symptom is most important for the nurse to report to the next shift?

Hematuria. (2) correct—hematuria is a sign of urinary tract calculi; 55% of hyperparathyroid clients have urinary tract calculi

The client reports chronic constipation to the nurse. The nurse in the health care clinic should advise the client to take which action?

Increase intake of cereals, fresh fruits, and vegetables. Plan the day to be home around the usual time of defecation. Establish daily exercise pattern.

The nurse cares for the client completing the first stage of labor. The client's partner is at the bedside and has been coaching according to exercises they learned in childbirth classes. Suddenly the client begins to shake and screams,"I can't stand this anymore!" The nurse encourages the partner to take which action?

Instruct the client to use shallow respirations during the contractions. entering transition phase of first stage of labor, rapid shallow breaths needed (pant breathing)

The nurse cares for the client following a cardiac catheterization. Two hours after the procedure, the nurse checks the client's insertion site in the antecubital space. The client reports the hand is numb. The nurse takes which action?

Notifies the health care provider. 3) CORRECT — absent or weak pulse or numbness could indicate problem with circulation; anticoagulants and vasodilators may be ordered

The nurse cares for the 17-year-old married male scheduled for a hernia repair. The nurse administers fentanyl 100 mcg with hydroxyzine pamoate 25 mg IM. Thirty minutes later the nurse discovers that the informed consent is unsigned. Which action by the nurse is best?

Notify the health care provider. Because they are married, they are emancipated and provide their own consent for treatment

The 2-year-old child is hospitalized. The nurse assesses the child and asks the parent about the activities the child does at home. Which activity would the nurse anticipate this child to perform?

Plays beside other children, but not with them. Builds 6-7 block towers. Can retrieve objects when asked to do so.

The nurse assesses the infant with a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which nursing action is MOST appropriate?

Position the infant on one side. (3) correct—will facilitate drainage of mucus from upper airway and will promote adjustment to breathing through the nose

Which is a priority nursing goal in the plan of care for a client diagnosed with paralysis due to stroke?

Prevent flexion of the affected extremities. (2) correct—flexor muscles are stronger than extensor muscles

The client diagnosed with Addison's disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which statement about Addison's disease?

Sodium intake should be increased during periods of stress. with decrease in aldosterone, there is an increased excretion of sodium; sodium intake should be increased

The young adult has a sprained right ankle. The nurse in the outpatient clinic teaches the client to walk with a cane. Where is the nurse positioned?

Standing on the client's left side and slightly behind the client. BEHIND AND ON STRONG SIDE

The nurse prepares the client for a liver biopsy. How does the nurse position the client?

Supine with arms raised above the head elevates the ribs to allow access to the liver; needle is inserted between two of the lower ribs or below the right ribcage

The nurse cares for a client after a bronchoscopy. The nurse is MOST concerned if which finding was observed?

Tachypnea. (3) correct—client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions

The nurse observes the staff member wearing regular clothing enter the room of the client. The nurse determines the staff member is using the proper precautions if the staff member cares for which client?

The client diagnosed with cancer reporting a sore mouth. indicates Candida, standard precautions required

The nurse sees the client with a 25-year history of alcohol abuse in the outpatient clinic. The client is being treated for chronic cirrhosis. Which symptom suggests to the nurse that the client is in the early stages of hepatic encephalopathy?

The client has difficulty describing what he does at work. The client states difficulty sleeping through the night. The client's spouse notes a change in the client's handwriting. NOT axterixis yet

The nurse instructs a client about how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor. Which action, if performed by the client, indicates to the nurse the need for further teaching?

The client milks the finger after sticking it. (4) correct—forces interstitial fluid to mix with capillary blood and dilutes the blood

The preschooler is brought to the emergency department after ingesting a bottle of baby aspirin. The nurse observes the preschooler for which signs and symptoms?

Tinnitus and gastric distress.

The nurse cares for the client with a three-chamber water-seal drainage system. The nurse notices the fluid in the water-seal chamber does not fluctuate. Which action by the nurse is best?

Anticipate the need for a chest x-ray. fluctuations stop with re-expansion of lung, x-ray will confirm

The nurse stabilizes the client with severe multiple trauma injuries from a motor vehicle accident. Which action does the nurse take next?

Arranges for clergy to visit with the client and family as requested. 2) CORRECT — provides the appropriate spiritual support during a crisis Limiting visiting hours to promote optimal rest is inappropriate.

One of the goals the nurse and a client diagnosed with posttraumatic stress disorder (PTSD) mutually agreed upon is that the client will increase participation in out-of-the apartment activities. Which recommendation, if made by the nurse, is MOST therapeutic to achieve this goal?

Join a support group, and participate in a victim assistance organization. (3) correct—support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath

The client is scheduled to have a parathyroidectomy. The nurse is most concerned if the client is observed eating quantities of food from which food group?

Milk products. low-calcium diet is recommended preoperatively

Butorphanol tartrate 1 mg IM is ordered for the woman 1 day postpartum. Which action is MOST important for the nurse to take after administering the medication?

Monitor the vital signs. (2) correct—decreases rate and depth of respirations

The RN obtains a urinalysis from the client reporting dysuria, urinary frequency, and discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based on which finding?

No WBCs or RBCs reported. (3) correct—with the client's symptoms, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding