nclex oct 1

A 27-year-old client with end-stage AIDS is being cared for by his wife at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about advance directives. At the next visit, the client states that since he and his wife filled out the advance directive form he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns? a. "Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself." b. "You don't need to feel that way. Your physician is required by law to sign your orders, and the hospice nurses will contact him with updates on your condition." c. "Many people feel that way when they are admitted into hospice. Although the focus of your care has changed from curative to supportive, your physician will still continue directing it." d. "It's understandable to feel that way, but clients with end-stage AIDS who have advanced directives generally experience a less painful death than those individuals who don't."

"Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself." Explanation: Option 1 provides correct information about advanced directives. The advanced directive outlines the client's treatment wishes should he be unable to communicate his wishes at any time during his illness. Option 3 doesn't address the purpose of the advanced directive.

What is the first action that a nurse should take after accidentally failing to administer an ordered medication? a. Notify the prescriber, nursing supervisor, and pharmacist. b. Give an extra dose at the next scheduled time. c. Write an incident report. d. Document the omission and the reason.

1 st Notify the prescriber, nursing supervisor, and pharmacist. 2nd documentation 3rd incident report NOT EXTRA OR DOUBLE DOSE

The nurse is assigned to care for four neonates. Which neonate should she assess first? a. A 5-hour-old, 6-lb, 9-oz (2,977 g) girl born by cesarean delivery b. A 5-hour-old, 8-lb, 3-oz (3,714-g) girl delivered vaginally c. A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally d. A 4-hour-old, 7-lb, 4-oz (3,289-g) boy born by cesarean delivery

A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally Explanation signs of hypoglycemia, which may lead to brain damage.

A client has gestational diabetes. When assisting with developing the plan of care for this client, which therapy would the nurse most likely identify as important for this client to manage glucose levels? a. diet b. long-acting insulin c. oral hypoglycemic drugs d. glucagon

a. diet

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond? a. "Your disease hasn't progressed enough to institute an advance directive." b. "It's important for us to have this information. You should review the document with your physician at every admission." c. "Advance directives aren't necessary for clients your age." d. "Thank you for providing this document; I'll include it in your permanent record."

b. "It's important for us to have this information. You should review the document with your physician at every admission."

The nurse is caring for an adolescent with type 1 diabetes who controls blood glucose levels well with twice-daily doses of insulin. The adolescent asks the nurse about participating in swimming after school without adversely affecting the blood glucose. What is the best response by the nurse? a. "You should eat a smaller lunch." b. "Make sure you have a snack before swimming." c. "On days you swim, administer more insulin in the morning." # risk of hypotension d. "Increase the amount of insulin you take at dinnertime." # risk of hypotension

"Make sure you have a snack before swimming." Explanation: Because exercise decreases the blood glucose level, the adolescent with type 1 diabetes should eat a snack before swimming to help prevent hypoglycemia. The adolescent could also eat a larger lunch, not a smaller one, to help maintain an adequate blood glucose level during exercise.

When the nurse turns a client, who has undergone a colon resection, wound dehiscence with evisceration occurs. What is the priority action by the nurse? a. call the healthcare provider b. apply a sterile saline dressing c. take a blood pressure and pulse d. provide gentle support to the area

1st # b. apply a sterile saline dressing to to prevent tissue drying and possible infection. 2nd# VS 3 notify PD 4 Gentle support to the area should be provided to prevent further dehiscence of the wound. Dehiscence requires surgically closure; the nurse should never try to close it.

The nurse is scheduled to administer an otic medication. Which action should the nurse perform first? a. Warm the solution to prevent dizziness. b. Place the client in the semi-Fowler's position. # lateral c. Hold an emesis basin under the client's ear. d. Check and verify the proper client's name.

1st Check and verify the proper client's name. # 7 rights

A client is 33 weeks' pregnant and has had diabetes since age 21. When checking the fasting blood glucose level, which value would indicate the client's disease is controlled? a. 45 mg/dL (2.5 mmol/L) b. 85 mg/dL (4.7 mmol/L) c. 120 mg/dL (6.67 mmol/L) d. 136 mg/dL (7.56 mmol/L)

85 mg/dL (4.7 mmol/L) Explanation: fasting blood glucose / pregnant # 60 to 95 mg/dL (3.33 to 5.28 mmol/L). hypoglycemia # l of 45 mg/dL (2.5 mmol/L) A blood glucose level below 120 mg/dL (6.67 mmol/L) is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dL (7.56 mmol/L) in a pregnant client indicates hyperglycemia.

A client is hospitalized with Guillain-Barré syndrome. The nurse will notify the physician of which significant data collection finding? a. Even, unlabored respirations b. Urine output of 40 ml/hour c. Soft, nondistended abdomen d. Warm, dry skin

Even, unlabored respirations Explanation: A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although all of the options are pertinent assessment data, those related to respiratory function and status are most significant.

The nursing staff is developing a care plan for a client who's receiving palliative care for end-stage leukemia. The client is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the client's care plan? a. Meeting with the pain management team to devise a more effective pain control plan b. Explaining that pain relief may not be possible because she's receiving maximum doses of pain medications c. Assessing whether the client is abusing the pain medications # typically develop drug toleranc d. Providing nonpharmacologic pain measures only, because maximum doses of pain

Meeting with the pain management team to devise a more effective pain control plan Explanation: Client comfort is the highest priority in palliative care. The nurse should meet with the pain management team to devise a plan to control the client's pain. Typically, doses are increased above the normal maximum doses to meet the client's needs.

A nurse is assisting with the plan of care for a client with a diagnosis of myasthenia gravis. Which time would be most appropriate for procedures and care to be completed? a. in the morning, with frequent rest periods b. before bedtime to promote rest c. all at one time to provide a longer rest period d. before meals to stimulate the client's appetite

a. in the morning, with frequent rest periods Explanation: Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort and improves with rest. Procedures should be performed in the morning because the client is most rested at that time. In addition, the client should have frequent rest periods in between procedures. Procedures should be avoided before meals, or the client with myasthenia gravis may become too exhausted to eat. Procedures should also be avoided at bedtime.

A nurse is reinforcing discharge instructions for a client with systemic lupus erythematosus SLE. Which intervention is most important for the nurse to include? a. consume no more than 2 liters(L) of fluid daily b. check blood sugar levels every morning before breakfast c. apply sunscreens with SPF higher than 15 daily d. avoid foods containing peanuts

apply sunscreens with SPF higher than 15 daily Explanation: or protective clothing, and/or avoid sun exposure to limit photosensitive rash or disease flares. Fluid restrictions, checking blood sugar and avoiding foods containing peanuts is not necessary for clients with SLE.

To treat a child's atopic dermatitis, a physician prescribes a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching? a. "I will gently scrape the skin before applying the cream to promote absorption." b. "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." c. "I will apply a moisturizing cream sparingly and will wash the affected area frequently." d. "I will spread a thick coat of hydrocortisone cream on the affected area and will wash this area once a week."

b. "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." Explanation: The parent should avoid washing the affected area with soap and water because this removes moisture from the horny layer of the skin. Applied in a thin layer, emollient cream holds moisture in the skin, provides a barrier to environmental irritants, and helps prevent infection. Topical steroid creams, such as hydrocortisone, should be applied sparingly as a light film; the affected area should be cleaned gently with water before the cream is applied. Scraping or abrading the skin may increase the risk of infection and alter drug absorption. Excessive application of steroidal creams may result in systemic absorption and Cushing's syndrome. Frequent washing dries the skin, making it more susceptible to cracking and further breakdown.

A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? a. Hypernatremia b. Hypokalemia c. Hypercalcemia d. Hyperphosphatemia # Hypophosphatemia

b. Hypokalemia Explanation: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. Hypophosphatemia may occur with insulin administration because phosphorus also enters the cells with insulin and potassium

After a physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond? a. Encourage the client to withdraw from the trial. b. Provide the information requested. c. Don't provide the information because it's beyond the scope of nursing practice. d. Tell the client that the information should come from the physician who first presented it to him.

b. Provide the information requested. Explanation: As part of the multidisciplinary team, the nurse is empowered to help the client better understand the process, as long as the nurse has an understanding of the treatment plan. Providing information about the clinical trial isn't beyond the scope of nursing practice. It isn't necessary for the information to come from the physician who originally presented it to the client.

17 A client has been admitted to the emergency department with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented in the chart shown, the nurse would expect the client to have which diagnosis? a. Crohn's disease b. pancreatitis c. irritable bowel syndrome d. peptic ulcer

b. pancreatitis Explanation SS pancreatitis # severe right upper quadrant pain, fever, nausea, and vomiting. Inflammation of the pancreas results in leukocytosis. Injured beta cells are unable to produce insulin, leading to hyperglycemia, which may be as high as 500 to 900 mg/dL. Lipase and amylase levels become elevated as the pancreatic enzymes leak from injured pancreatic cells. Calcium becomes trapped as fat necrosis occurs, leading to hypocalcemia.

29 A nurse is caring for clients in a subacute unit. Which client care takes priority? a. changing a colostomy bag that is full b. suctioning a tracheostomy client with oxygen saturation of 90% c. administering pain medication to a client with a pain level of 7 out of 10 d. changing a dressing on a wound with serosanguinous drainage

b. suctioning a tracheostomy client with oxygen saturation of 90% Explanation: Using Maslow's hierarchy of need, the priority is maintaining airway. If the airway is not maintained, the client can die of asphyxia. Changing a dressing and colostomy are necessary but not emergent. Administering pain medication is the next priority after airway.

Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale? a. If no improvement is seen after 1 week, an antibiotic will be prescribed. b. The drug loses its efficacy after prolonged use. c. Excessive use can have adverse effects, such as skin atrophy and fragility. d. If no improvement is seen, a stronger concentration will be prescribed.

c. Excessive use can have adverse effects, such as skin atrophy and fragility.

The nurse administers hydromorphone 2 mg I.V. to a client complaining of incisional pain. While documenting the administration, the nurse notes that the medication was prescribed by the I.M. route. Which action should the nurse take? a. Document that the medication was given but don't document the injection site. b. Document that the medication was given by the I.V. route. c. Obtain vital signs and notify the physician and nursing supervisor of the error. d. Document that the medication was given according to the physician's order.

c. Obtain vital signs and notify the physician and nursing supervisor of the error.

Which steps should the nurse follow to insert a straight urinary catheter? a. Create a sterile field, drape the client, clean the meatus, and insert the catheter only 6". b. Put on gloves, prepare the equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6". c. Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. d. Prepare the client and the equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows. # indwelling catheter

c. Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should: a. inform the sister that she doesn't have the power to assign a different physician. b. ask the dismissed physician if the client ever stated she wanted a different physician. c. abide by the wishes of the sister who is the durable power of attorney agent. d. politely ignore the sister's statement and continue to call the dismissed physician for orders.

c. abide by the wishes of the sister who is the durable power of attorney agent.

A client reports excessive flatulence. Which food, reported by the client as consumed regularly, may be responsible for this? a. cauliflower b. ice cream c. meat d. potatoes

cauliflower Explanation:

When teaching the parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction? a. "Reduce your child's caloric intake to decrease cardiac demand." b. "Relax discipline and limit-setting to prevent crying." c. "Make sure your child avoids contact with small children to reduce overstimulation." d. "Try to maintain your child's usual lifestyle to promote normal development."

d. "Try to maintain your child's usual lifestyle to promote normal development."

A client performs monthly self-breast examinations. Which finding should the client promptly report? a. Freely movable masses that become tender before menses b. Multiple tender, round masses in both breasts c. Areolae that are bilaterally darkened in color d. A hard, nontender mass in the upper outer quadrant of the left breast

d. A hard, nontender mass in the upper outer quadrant of the left breast Explanation Hard, nontender masses are associated with cancerous tumors. Darkened areolae # hormonal changes, E.G pregnancy Multiple round masses in both breasts that become tender before menses are characteristic findings in fibrocystic breast disease, which can be discussed at yearly checkups.

A 2-year-old returns from surgery after a bowel resection as a result of Hirschsprung disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority? a. Change the surgical dressing. b. Suction the nasopharynx frequently to remove secretions. c. Irrigate the colostomy with 100 mL of normal saline solution. d. Auscultate lung sounds.

d. Auscultate lung sounds. to evaluate pulmonary function. Explanation Suctioning should be performed only if the client cannot maintain a patent airway. Colostomy irrigation is not warranted.

38 A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan? a. Administer antibiotics whenever the baby has a cold. b. Clean the external ear canal daily. c. Avoid getting the ears wet while bathing or swimming. d. Place the baby in an upright position when giving a bottle.

d. Place the baby in an upright position when giving a bottle.

A nurse is caring for several neonates in a busy nursery. When weighing a neonate, which action should the nurse take? a. Leave the diaper on for comfort. # UNDRESSED b. Place a sterile paper on the scale for infection control. # CLEAN SCALE c. Keep a hand on the neonate's abdomen for safety. # ABOVE ADOMEN d. Weigh the neonate at the same time each day for accuracy.

d. Weigh the neonate at the same time each day for accuracy.

The nurse is admitting a client who states, "I was bit by a brown recluse spider." Which observations made by the nurse would indicate the client's report is accurate? a. bull's-eye rash # Lyme disease b. herald patch of oval lesions # pityriasis rosea c. line of papules and vesicles that appear 1 to 3 days after exposure # poison ivy d. painful rash around a necrotic lesion

d. painful rash around a necrotic lesion

44 The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for HIV. The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse? a. "It's important to protect your unborn child so I'll reassign the client." b. "If you can't care for our clients, you'll need to take a leave of absence from work." c. "I'll call the infection control department to determine whether it's safe for you to care for this client." d. "It's inappropriate to refuse this assignment; all clients should be treated equally."

"It's inappropriate to refuse this assignment; all clients should be treated equally." Explanation: According to the ethical principle of autonomy, all clients should be treated equally regardless of disease and social or economic status. Pregnancy shouldn't prevent the nurse from caring for an HIV-infected client.

A 6-week-old infant who is not breathing is brought to the emergency department by the parents. A preliminary diagnosis of sudden infant death syndrome SIDS is made. Which nursing intervention is a priority? a. Call their spiritual advisor. b. Explain the etiology of SIDS. c. Allow the parents to see their infant. d. Collect the infant's belongings and give them to the parents.

Allow the parents to see their infant. Explanation: The parents need time with their infant to assist with the grieving process. Calling their pastor and collecting the infant's belongings are also important steps in the care plan, but are not priorities. The parents will be too upset to understand an explanation of SIDS at this time.

A nurse on the orthopedic floor is caring for a group of clients who are in various stages of recovery after knee replacement surgery. One client is ready for discharge. How should the nurse proceed with discharge planning? a. Begin discharge teaching for the client who is ready for discharge when he has finished eating breakfast. b. Discuss home care needs with those who will be discharged in 2 days. c. Obtain discharge teaching orders from the physician for those who will be discharged in 2 days. d. Complete the discharge instructions for the client who is being discharged, and allow time for him to ask questions.

Complete the discharge instructions for the client who is being discharged, and allow time for him to ask questions. Explanation: The nurse can provide discharge teaching without a physician's order.

A client is evaluated for hypertension. The physician prescribes atenolol, 50 mg by mouth daily. Atenolol should have which therapeutic effect on the client? a. Decreased cardiac output and systolic and diastolic blood pressure b. Increased cardiac output and systolic and diastolic blood pressure c. Decreased blood pressure with reflex tachycardia d. Decreased peripheral vascular resistance

Decreased cardiac output and systolic and diastolic blood pressure Explanation: As a long-acting, selective beta1 blocker, atenolol 1 decreases cardiac output and systolic and diastolic blood pressure; 2 however, increases peripheral vascular resistance at rest and with exercise. 3 bradycardia,

What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum? a. Dehydration b. Puerperal infection c. Mastitis d. Chorioamnionitis

Dehydration Explanation: A slight temperature elevation from dehydration is common during the first 24 hours after delivery. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after delivery, excluding the first 24 hours.

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the client's medication drawer. What priority action should the nurse implement? a. Discard the syringe to avoid a medication error. b. Obtain a label for the syringe from the pharmacy. c. Use the syringe because it looks like it contains the same medication the nurse prepared to give. d. Call the day nurse to verify the contents of the syringe.

Discard the syringe to avoid a medication error.

The nurse is conducting a follow-up phone call with the parent of a child with nephrosis who was recently discharged. Which statement by the parent indicates the discharge instructions are being followed correctly? SATA a. "I am weighing my child every morning and keeping a logbook." b. "My child is scheduled for his MMR vaccine next week." c. "I am administering my child's prednisone once a day, every day." d. "I am keeping my child out of school indefinitely." e. "If my child's morning urine has 2+ protein for 2 days in a row, I will call the health care provider."

Explanation: Initial therapy with prednisone is 60 mg/m2/day for 4 weeks. A single daily dose has fewer side effects. & A child on prednisone should not receive a live-virus vaccine like MMR. Daily weights and urine protein checks should be measured and logged. Parents should notify the health care provider if the urine is 2+ for protein for 2 days in a row.

A nurse is obtaining a health history from a male senior citizen. The client states that he is having urinary hesitancy, slight dysuria, and dribbling. He denies reports of hematuria. Identify the area where the nurse anticipates the primary cause of the urinary dysfunction.

Explanation: Note that the X is over the prostate gland. The walnut-sized prostate gland lies beneath the bladder and surrounds the urethra. When the prostate gland becomes enlarged, which commonly occurs as a male ages, urination becomes affected as the prostate gland narrows the passage of urine through the urethra.

The nurse is providing care to a pregnant adolescent client in the first trimester. Which intervention would the nurse identify as the highest priority? a. Schedule the client for a screening glucose tolerance test. b. Make sure the client receives nutritional counseling and reinforce the education. c. Teach the client that there is increased risk for having a macrosomic neonate. d. Monitor the client for signs and symptoms of placenta previa.

Make sure the client receives nutritional counseling and reinforce the education. Explanation option a & d # no indicate gestational diabetes or placenta previa opt c # Adolescent clients are at risk for delivering low-birth-weight neonates, not macrosomic neonates

A client diagnosed with renal calculi is experiencing severe pain despite having received pain medication. A nurse pages a physician. Which intervention can the nurse perform while awaiting the physician's response? a. Assist the client to ambulate in the hallway. b. Explain that the client can't safely take any more pain medication. c. Provide the client with a heating pad. # need ODERED d. Perform nonpharmacologic pain interventions.

Perform nonpharmacologic pain interventions. Explanation: e.g repositioning, massage, and distraction. A client experiencing severe pain will most likely be able to tolerate a higher dose of pain medication.

The nurse is teaching accident prevention to the parents of a toddler. Which of the following instructions is appropriate for the nurse to tell the parents? a. The toddler should wear a helmet when rollerblading. # not toddler age b. Place locks on cabinets containing toxic substances. c. Teach toddler water safety. # apply on school-age due to lack of cognitive development d. Don't allow the toddler to use pillows when sleeping. # apply for infant

Place locks on cabinets containing toxic substances. Explanation: All household cleaners and poisons should be locked with childproof locks. The toddler's curiosity and the ability to climb and open doors and drawers makes poisoning a concern in this age-group.

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care? a. maintaining current weight b. encouraging ambulation c. providing mouth care d. promoting bowel rest

Promoting bowel rest is the priority during an acute exacerbation. This is accomplished by decreasing activity and initially putting the client on nothing-by-mouth (NPO) status. Weight loss may occur, but the priority is bowel rest.

A pregnant client in the second trimester reveals feeling very anxious because of a lack of knowledge about giving birth. Which intervention by the nurse is most appropriate for this client? a. Provide the client with the information and teach the skills needed to understand and cope during birth. b. Provide the client with written information about the birthing process. c. Have a more experienced pregnant client assist this client. d. Do nothing in hopes that the client will begin coping as the pregnancy progresses.

Provide the client with the information and teach the skills needed to understand and cope during birth. Explanation: Because the client is in the second trimester, the nurse has ample time to establish a trusting relationship and to teach in a style that fits the client's needs. Written information would be effective only in conjunction with teaching sessions.

A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus? a. urine b. sputum c. feces d. blood

The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.

As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report? a. To reprimand the involved staff members for their actions b. To identify the learning needs of staff to prevent incident recurrences c. To reprimand the nurse-manager responsible for the unit d. To hold people accountable for their actions

To identify the learning needs of staff to prevent incident recurrences Explanation: The purpose of an incident report is threefold: to identify ways to prevent incident recurrences, to identify patterns of care problems, and to identify facts surrounding each incident. Incident reports aren't used to hold people accountable for their actions, to punish those involved in the incident, or to punish the nurse-manager responsible for the unit.

The nurse receives a medication order from a health care provider over the telephone. Which nursing intervention is a priority when receiving a telephone order? a. Inform the health care provider that the Nurse Practice Act prohibits taking medication orders over the telephone. b. Verify the order by repeating it back to the health care provider over the phone. c. Request that a second health care provider repeat the order to the nurse over the telephone. d. Insist that the health care provider sign the medication order within 1 hour.

Verify the order by repeating it back to the health care provider over the phone. Explanation: When taking a medication order over the telephone, standard practice requires verbal verification of the order and the health care provider's written signature within 24 hours.

Which action is appropriate for the nurse to perform when administering digoxin to an infant? a. Mix the digoxin with the infant's food. b. Double the subsequent dose if a dose is missed. c. Give the digoxin with antacids when possible. d. Withhold the dose if the apical pulse rate is less than 90 beats/minute.

Withhold the dose if the apical pulse rate is less than 90 beats/minute. Explanation: Digoxin is used to decrease heart rate; however, the apical pulse must be carefully monitored to detect a severe reduction. Antacids may decrease absorption of digoxin. Mixing digoxin with other food may interfere with accurate dosing. Double-dosing should never be done.

The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all of the following steps except: a. keep the client in one position to decrease bleeding. b. maintain the client in a quiet environment. c. position the client to prevent airway obstruction. d. administer I.V. fluid as ordered and monitor the client for signs of fluid volume excess.

a. keep the client in one position to decrease bleeding. FALSE need carefully reposition at least every hour To maintain a PATENT airway.

To encourage the preschooler to take deep breaths for lung auscultation, which nursing action is appropriate? a. Allow the client to exercise in the exam room. b. Demonstrate what a cough is. c. Have the client blow a tissue. d. Discuss the importance of a deep breath.

c. Have the client blow a tissue.

A client arrives in the emergency department with smoke inhalation due to a house fire. What should be the nurse's priority action for this client? a. checking the oral mucous membranes b. checking for any burned areas c. obtaining a medical history d. determining if the client can speak

determining if the client can speak Explanation: The nurse's priority is to make sure the airway is open and the client is breathing.

The nurse is caring for a client that has taken an overdose of acetaminophen. For which initial complication should the nurse closely monitor the client? a. brain damage b. heart failure c. hepatic damage d. kidney stones

hepatic damage

The nurse is helping the adolescent deal with diabetes. What characteristic of adolescence should be considered? a. desire to be an individual b. need to be like peers c. preoccupation with future plans d. ability to educate peers about the seriousness of the disease

need to be like peers Explanation: Adolescents appear to have the most difficulty adjusting to diabetes. Adolescence is a time when being "perfect" and being like one's peers are emphasized, and having diabetes means the adolescent is different.

An older adult client with heart failure and 2+ pitting edema is prescribed furosemide. Due to the effects of furosemide, which supplemental medication would the nurse expect to see ordered for this client? a. Diflucan b. digoxin c. potassium d. sodium bicarbonate

potassium

A child is diagnosed with recurrent urinary tract infections (UTIs). Which treatment does the nurse anticipate reinforcing education regarding? a. frequent catheterizations b. prophylactic antibiotics c. limited activities d. surgical intervention # referred antibiotic med

prophylactic antibiotics

The licensed practical nurse (LPN) is part of a team caring for a group of clients in a community. Which task carried out by the LPN best describes team nursing? a. providing total care to clients with other health personnel b. providing care for church members at a community worship center # called parish nursing c. administering medication to all of the clients in the unit # is functional nursing d. providing total care to a group of clients in the unit # considered primary nursing

providing total care to clients with other health personnel

56 If both kidneys are involved with Wilms tumor, the nurse should expect that treatment before surgery might include which method? a. peritoneal dialysis b. abdominal gavage c. radiation and chemotherapy d. antibiotics and IV fluid therapy

radiation and chemotherapy Explanation: If both kidneys are involved, the child may be treated with radiation therapy or chemotherapy preoperatively to shrink the tumor, allowing more conservative surgery. Peritoneal dialysis would be needed only if the kidneys were not functioning. Abdominal gavage is not indicated. Antibiotics aren't needed because Wilms tumor is not an infection.

48 A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the health care provider to prescribe: a. dinoprostone. # induce fetal expulsion and promote cervical dilation and softening b. betamethasone. # accelerate surfactant production in preterm labor c. oxytocin d. terbutaline# impede uterine blood flow — for example, in hemorrhage.

terbutaline 1 a selective beta2-receptor agonist 2 is used to inhibit preterm uterine contractions.