NCLEX Prep Q/A with Rationale

to enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST important for the nurse to select a site that is which of the following? 1. muscular 2. near the heart 3. non-hairy 4. bony prominence

"non-hairy" hair interferes with absorption. a skin site free of hair helps ensure drug absorption.

a pediatric with a congenital heart defect is admitted with a diagnosis of heart failure. digoxin 0.12 mg PO daily is prescribed for the client. the bottle contains 0.05 mg of digoxin in 1 mL of solution. which of the following amounts of digoxin should the nurse administer to the client? 1. 1.2 mL 2. 2.4 mL 3. 3.5 mL 4. 4.2 mL

"2.4 mL" (0.05 mg / 1 mL) x 0.12 mg = 2.4 mL

the. nurse is calculating the IV flow rate for a post-operative client. the client is to receive 3,000 mL of LR solution IV infused over 24 hours. the IV administration set has a drop factor of 10 g/tt. the nurse should regulate the client's IV administration set to deliver how many drops per minute? 1. 18 2. 21 3. 35 4. 40

"21" (3000 x 10) / (24 x 60)

a client is ordered 1,000 mL of 5% dextrose in 1/2 normal saline solution IV to infuse over 8 hours. the IV administration set tubing delivers 15 drops per mL. the nurse should regular the flow rate so it delivers how many drops of fluid per minute? 1. 15 2. 31 3. 45 4. 60

"31" (1000/8) mL/hour x (15/60) gtt/min (60 mins in an hour)

a client is to receive 3,000 mL of normal saline solution IV infused over 24 hours. the IV administration tubing delivers 15 drops per mL. the nurse should regulate the flow rate so that the client receives how many drops of fluid per minute? 1. 21 2. 28 3. 31 4. 42

"31" (3000 mL /24 hours x 15 drops/mL) / 60 mins = drops per minute

a client reports pain in the right lower extremity, the primary HCP prescribes codeine 60 mg and aspirin 650 mg PO Q4H PRN for pain. Each codeine tablet contains 15 mg of codeine. Each aspirin tablet contains 325 mg of aspirin. Which of the following should the nurse administer? 1. 2 codeine tablets and 4 aspirin tablets 2. 4 codeine tablets and 3 aspirin tablets 3. 4 codeine tablets and 2 aspirin tablets 4. 3 codeine tablets and 3 aspirin tablets

"4 codeine tablets and 2 aspirin tablets" 60 mg codeine = 4 15 mg tabs 650 mg aspirin = 2 350 mg tabs

the nurse is assisting the HCP with removal of a chest tube. which of the following instructions should the nurse give to the client before chest tube removal? 1. exhale and bear down 2. hold your breath for 5 seconds 3. inhale and exhale rapidly 4. cough as hard as you can

"exhale and bear down" Valsalva maneuver (exhaling and bearing down) increases intrathoracic pressure to prevent air from entering the chest during tube removal. inhaling and exhaling rapidly is unsafe. holding breathing or coughing are unnecessary.

a nurse in the outpatient clinic evaluates the Mantoux test results of a client whose history includes treatment during the past year for AIDS-related infection. the nurse should document a positive reaction if there is an area of induration measuring which of the following? 1. 1 mm 2. 3 mm 3. 4 mm 4. 7 mm

"7 mm" the Mantoux test is for TB immunity. it is given intradermally in the forearm and read 48-72 hours after. 15 mm (or greater) induration (hard are under the skin) for persons with no known TB risk factors is significant. 5 mm (or greater) area is positive for a client with HIV-infection history. this does not mean active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease.

the nurse in the newborn nursery has just received hand-off report. which of the following infants should the nurse see FIRST? 1. a 2-day-old client lying quietly alert with a heart rate of 185 BPM 2. a 1-day-old client crying, with a bulging anterior fontanel 3. a 12-hour-old client being held, the respirations are 45 breaths/min and irregular 4. a 5-hour-old whose hands and feet appear blue bilaterally during sleep

"a 2-day-old client lying quietly alert with a heart rate of 185 BPM" physical stability is the main concern, so the most unstable client must be seen first. the client with a HR of 185 is not WDL (120-160 BPM) and would be seen first. the 1-day-old is crying, causing increased ICP and a bulging anterior fontanel. the 12-hour-old with a RR of 45 is WDL (30-60 breaths/min) with apneic episodes. the 5-hour-old client is experiencing acrocyanosis which normally occurs for 2-6 hours after delivery due to poor peripheral circulation.

after receiving report, the nurse should see which of the following clients FIRST? 1. a client in sickle-cell crisis experiencing an IV infiltration 2. a client with leukemia receiving a RBC transfusion 3. a client scheduled for an elective bronchoscopy 4. a client reporting a leaking colostomy bag

"a client in sickle-cell crisis experiencing an IV infiltration" IV fluids are critical for treating the clotting and pain associated with sickle cell crisis. all other clients are stable.

the nurse on a postpartum unit is preparing 4 clients for discharge. it would be MOST important for the nurse to refer which of the following clients for home care? 1. a primipara client who delivered a 7lb (3.2 kg) infant 2 days ago 2. a multipara client who delivered a 9lb (4 kg) infant by cesarean section 2 days ago 3. a multipara client who delivered 1 day ago and is reporting cramping 4. a client who delivered by cesarean section and is reporting burning on urination

"a client who delivered by cesarean section and is reporting burning on urination" need to meet the client's needs, so physical stability is the nurse's first concern. the most unstable client is the client who is showing signs of a UTI (requiring follow-up)

the nurse on the surgical floor is receiving hand-off report from the previous shift. which of the following clients should the nurse see first? 1. a client admitted 3 hours ago with a gunshot wound with a 1.5 cm area of dark drainage on the dressing 2. a client who had a mastectomy 2 days ago with 23 mL of serosanguinous fluid in the wound drain 3. a client with a collapsed lung due to an accident with no chest drainage noted in the previous 8 hours 4. a client who had an abdominal-perineal resection 3 days ago who is reporting chills

"a client who had an abdominal-perineal resection 3 days ago who is reporting chills" physical stability is the nurse's first concern. the must unstable client should be seen first. the POD3 client reporting chills is at risk for peritonitis and should be assessment for further symptoms of infection.

the nursing team consists of 1 RN, 2 LPN/LVNs, and 3 UAPs. The RN should care for which of the following clients? 1. a client with a chest tube who is ambulating in the hallway 2. a client with a colostomy who requires colostomy irrigation assistance 3. a client with right-sided stroke who requires assistance with bathing 4. a client who is refusing medication to treat cancer of the colon

"a client who is refusing medication to treat cancer of the colon" the client who is refusing cancer medication requires the further assessment skills of the RN. the client with a chest tube is stable and can be charged to the LPN/LVN. the client with a colostomy requiring irrigation assistance can be charged to the LPN/LVN as this procedure has a predictable outcome. the client requiring assistance bathing can be charged to the UAP.

the nurse in an outpatient clinic is supervising student nurses as they administer influenza vaccinations. the nurse should question influenza vaccine administration to which of the following clients? 1. a client who is allergic to shellfish 2. a client who reports a sore throat 3. a client who lives in a group home 4. a client diagnosed with heart failure

"a client who reports a sore throat" vaccine should be deferred in presence of acute respiratory disease. shellfish allergy is not a contraindication for the influenza vaccine. clients who live in group homes or have chronic cardiovascular conditions are given priority to receive vaccines in the face of vaccine shortages.

the nurse is caring for clients in the outpatient clinic. which of the following phone calls should the nurse return FIRST? 1. a client diagnosed with hepatitis A who states: my arms and legs are itching 2. a client with a cast on the right leg who states: i have a funny feeling in my right leg 3. a client diagnosed with osteomyelitis of the spine who states: i am so nauseous that i can't eat 4. a client diagnosed with rheumatoid arthritis who states: i am having trouble sleeping

"a client with a cast on the right leg who states: i have a funny feeling in my right leg" physical stability is the nurse's first concern. the most unstable client will be seen first (think ABC's). the client stating that their right leg (that is in a cast) feels funny may have neurovascular compromise and requires immediate assessment of circulation. the client with hepatitis A is experiencing itching due to the accumulation fo bile salts under the skin and can be treated with calamine lotion and antihistamines. difficulty eating and sleeping both require assessment, but are not top priority.

a nursing team consists of an RN, an LPN/LVN, and a UAP. the nurse should assign which of the following clients to the LPN/LVN? 1. a client with a diabetic ulcer that requires a dressing change 2. a client with cancer who is reporting bone pain 3. a client with terminal cancer being transferred to hospice home care 4. a client with a fracture of the right leg who asks to use the urinal

"a client with a diabetic ulcer that requires a dressing change" LPN/LVN assists with implementation of care, performs procedures, differentiates normal from abnormal, cares for stable clients with predictable conditions, has knowledge of asepsis and dressing changes, administers medications (varies). the client with a diabetic ulcer that requires a dressing change is a stable client with an expected outcome. the other cases require RN judgement (cancer, hospice transfer) or is a standard, unchanging procedure for a UAP (urinal).

the nurse is caring for clients on the pediatric unit. a client with second- and third-degree burns on the right thigh is being admitted. the nurse should assign the new client to which of the following roommates? 1. a client with chickenpox 2. a client with asthma 3. a client who developed acute diarrhea after antibiotic 4. a client with methicillin-resistant staphylococcus aureus

"a client with asthma" lowest risk of cross contamination because the client with asthma is not infectious. burns increase risk for infection. all other client's pose an increased risk for infection in the presence of a client with second- and third-degree burns.

the nurse is caring for clients in the emergency department of an acute care facility. four clients have been admitted in the last 20 minutes. which of the following admissions should the nurse see FIRST? 1. a client with chest pain unrelieved by nitroglycerin 2. a client with third-degree burns to the face 3. a client with a fractured left hip 4. a client reporting epigastric pain

"a client with third-degree burns to the face" face, neck, chest, and abdominal burns can cause severe edema that restricts the airway. airway issues take priority.

after a laparoscopic cholecystectomy, the client reports abdominal pain and bloating. which of the following responses by the nurse is best? 1. increase intake of fresh fruits and vegetables 2. i'll give you the prescribed pain medication 3. a walk down the hallway may help you 4. you may need an indwelling urinary catheter

"a walk down the hallway may help you" Co2 insufflated during laparoscopic surgery causes pain. ambulation increases absorption and reduces pain. the first option is in relation to constipation, of which this patient has no indication of (yet). an indwelling urinary catheter does not relieve the pain related to CO2 insufflation.

the nurse is caring for a client in the prenatal clinic. the nurse notes that the client's medical record contains the following information: blood type AB, Rh-, serology: negative, indirect Coombs test: negative, fetal paternity: unknown. The nurse should anticipate taking which of the following actions? 1. Rho (D) immune globulin 2. schedule an amniocentesis 3. obtain a direct Coombs test 4. assess maternal alpha fetoprotein level

"administer Rho (D) immune globulin" Rho (D) immune globulin is given to unsensitized Rh- mother after delivery or abortion of an Rh-positive infant or fetus to prevent development of sensitization. it is also given at 26-28 weeks' gestation (recommended). direct Coombs test is done on cord blood after delivery.

the nurse is caring for a client with a diagnosis of chronic bronchitis. the client has audible wheezing and oxygen saturation 85%. four hours ago, the oxygen saturation was 88%. it is MOST important for the nurse to take which of the following actions? 1. give beclomethasone, 2 puffs via metered-dose inhaler 2. auscultate the client's bilateral breath sounds 3. increase O2 flow rate to 8L/min via mask 4. administer albuterol, 2 puffs via metered-dose inhaler

"administer albuterol, 2 puffs via metered-dose inhaler" a bronchodilator, such as albuterol, relaxes bronchial smooth muscles and increases airflow to the lungs. after giving the bronchodilator, beclomethasone (a steroid) may be considered. this situation does not require further assessment (auscultation), the nurse needs to implement treatment in order to increase the client's oxygen saturation level. increasing the O2 flow rate will increase the client's blood oxygen level and may cause respiratory depression 2/2 CO2 narcosis.

arterial blood gas (ABG) analysis is prescribed for a client diagnosed with pneumonia (PNA). after obtaining the blood sample, it would be MOST appropriate for the nurse to take which of the following actions? 1. obtain ice for the blood sample 2. apply direct pressure to the site 3. apply a sterile dressing to the site 4. assess the site for hematoma formation

"apply direct pressure to the site" pressure applied directly to the arterial puncture site prevents bleeding and hematoma formation. the blood sample should be put on ice if not analyzed immediately, but this is not the most important action. a sterile dressing is not necessary. it is more important to prevent hematoma formation (using the priority action- pressure on the puncture site).

the primigravida client at 32 weeks' gestation comes to the clinic for her initial prenatal visit. the client reports periodic headaches and continually bumping into things. the nurse observes numerous bruises in the various stages of healing around the client's breasts and abdomen. vital signs include BP 120/80, HR 72, RR 18, and fetal heart tones 142 BPM. which of the following responses by the nurse is BEST? 1. are you battered by your partner? 2. how do you feel about being pregnant? 3. tell me about your headaches 4. you may be more clumsy due to your size

"are you battered by your partner" evidence of injury should be investigated. assess head, neck, chest, abdomen, breasts, and upper extremities. symptoms of domestic abuse include frequent visits to primary HCP's office or ED for unexplained trauma, evidence of multiple old injuries, evasive replies, flinching when approached or touched, and being cued or silenced by accompanying family member. determine safety of client.

a client newly diagnosed with major neurocognitive disorder (NCD) due to Alzheimer's disease is admitted to the unit. which of the following actions by the nurse is BEST? 1. place the client in a semi-private room away from the nurse's station 2. ask family members to wait in the waiting room during the admission process 3. assign a different nurse daily to care for the client 4. ask the client to state the current date

"ask the client to state the current date" assessment is the first step to planning care. for purposes of safety, the client should be near the nurse's station. familiar people decrease confusion in an unfamiliar environment, so the family would not be told to wait in the waiting room. consistency is important with clients with neurological disorders.

when collecting a 24-hour urine specimen for creatinine clearance, it is MOST important for the nurse to do which of the following? 1. obtain a prescription for an indwelling urinary catheter 2. weigh the client before beginning the urine collection 3. discard the last specimen before the collection period ends 4. ask whether the collection container contains a preservative

"ask whether the collection container contains a preservative" save all urine in a container with no preservatives. refrigerate or keep the specimen container on ice. collect all the urine voided during the time 24-hour period. catheterization and weighing are not necessary.

the nurse is caring for a client 5 hours after a pancreatectomy for cancer of the pancreas. the nurse observes minimal drainage from the NG tube. it is MOST important for the nurse to take which of the following actions? 1. notify HCP 2. monitor VS Q15min 3. assess NG tube for kinking 4. replace NG tube immediately

"assess NG tube for kinking" assess prior to implementing or contacting HCP. maintain tubing in dependent position to promote drainage. monitoring vital signs does not address lack of drainage.

the home care nurse is performing chest physiotherapy on a client with chronic airflow limitations (CAL). which of the following actions should the nurse take FIRST? 1. perform chest physiotherapy prior to meals 2. auscultate breath sounds before procedure 3. administer bronchodilators after the procedure 4. percuss each lobe prior to asking the client to cough

"auscultate breath sounds before procedure" helps identify areas of the lung that require drainage. auscultate breath sounds again after procedure to determine effectiveness. bronchodilators are given before chest physiotherapy in order to dilate the bronchioles and to liquefy secretions, but the nurse should auscultate first. percussion helps loosen thick secretions (but don't use in older clients with osteoporosis r/t risk for fracture), but the nurse should auscultate first.

the nurse is preparing discharge teaching for a client with a new colostomy. the nurse knows teaching was successful when the client chooses which of the following menu options? 1. sausage, sauerkraut, baked potato, and fresh fruit 2. cheese omelet with bran muffin and fresh pineapple 3. pork chop, mashed potatoes, turnips, and salad 4. baked chicken, boiled potato, cooked carrots, and yogurt

"baked chicken, boiled potato, cooked carrots, and yogurt" provides balanced nutrition, high protein, low residue, low fat, and non irritating foods. sausage and sauerkraut are gas producing and should be avoided with a new colostomy. bran muffin and fresh fruit are high in fiber (residue). turnips are odor-causing and salad is high residue.

the nurse is teaching a class on natural family planning. which of the following statements by a client indicates that teaching has been successful? 1. when i ovulate, my basal body temperature will elevate for 2 days and then decrease 2. my cervical mucous will become thick, cloudy, and sticky when i ovulate 3. because i am regular, i will be fertile about 14 days from the beginning of my period 4. when i ovulate, my cervix will feel firm

"because i am regular, i will be fertile about 14 days from the beginning of my period" natural family planning involves the periodic abstinence from intercourse during fertile period as a means of contraception. fertile period may be determined by a drop in basal temperature before and a slight rise after ovulation, and/or a change in cervical mucous from thick, cloudy, and stick during non-fertile period to more abundant, clear, thin, stretchy, and slippery during ovulation.

the nurse in a primary care clinic is caring for a client with a history of smoking 1 pack of cigarettes per day for 45 years and drinking 2 beers per day. the client reports a non-productive cough, chest discomfort, and dyspnea. the nurse auscultates isolated wheezing in the right middle lobe. it would be MOST important for the nurse to complete which of the following prescriptions? 1. arrange for pulmonary function testing 2. schedule a routine echocardiogram 3. call the radiology department to arrange a CXR 4. obtain a sputum specimen for C&S testing

"call the radiology department to arrange a CXR" a CXR helps determine the cause of the client's symptoms. based on the smoking history, symptoms, and presence of wheezing, the client may have a chest mass that would be visible on chest x-ray.

the nurse is caring for a client who was involved in a MVA 1 day ago. the client has a double-lumen tracheostomy tube with a cuff. which of the following actions should the nurse perform? 1. change tracheostomy dressing Q8H and PRN 2. change the tracheostomy ties Q48H 3. maintain the inner cannula in place at all times 4. push the outer cannula back in if it accidentally dislodges

"change tracheostomy dressing Q8H and PRN" doing so prevents infection and moisture associated skin breakdown. change the tracheostomy ties when needed. keep the inner cannula of the tracheostomy in place at all times, except when cleaning. do NOT push the dislodged tracheostomy back in the stoma; maintain a patent airway and contact the HCP.

a client with a history of alcohol use disorder is brought to the emergency department in an agitated state. the client is vomiting and diaphoretic, and states that it has been 5 hours since the last drink. the nurse would expect to administer which of the following medications? 1. chlordiazepoxide 2. disulfiram 3. methadone 4. naloxone

"chlordiazepoxide" this is an anti-anxiety agent used to treat the symptoms of acute alcohol withdrawal. the patient stated that last drink was 5 hours ago, and disulfiram (used as a deterrent to compulsive drinking) is contraindicated within 12 hours of alcohol consumption.

the nurse is caring for a client with a cast on the left leg. the nurse would be MOST concerned if which of the following is observed? 1. capillary refill time is less than 3 seconds 2. client reports discomfort and itching 3. client reports tightness and pain 4. client's foot is elevated on a pillow

"client reports tightness and pain" pain and tightness may develop is swelling occurs and the cast becomes too tight. if left untreated, compartment syndrome may develop. capillary refill less than 3 seconds, discomfort, and itching are WDL. elevation of the client's foot on a soft surface (pillow) helps relieve edema and is the correct position to allow sufficient perfusion.

the nurse in the ED is caring for a client admitted with chest pain. which of the following laboratory findings would MOST concern the nurse? 1. erythrocyte sedimentation rate (ESR): 10 mm/hr 2. hematocrit (Hct): 42% 3. creatinine phosphokinase-MB (CK-MB): 4 ng/mL 4. serum glucose: 100 mg/dL

"creatinine phosphokinase-MB (CK-MB): 4 ng/dL this enzyme is specific to the myocardium and indicates tissue necrosis or injury to heart muscle. normal value is 0-3 ng/dL.

a nurse is supervising a group of elderly clients in a long-term care facility. the nurse knows that the elderly are at greater risk of developing sensory deprivation for which of the following reasons? 1. increased sensitivity to the side effects of medications 2. decreased visual, auditory, and gustatory abilities 3. isolation from their families and familiar surroundings 4. decreased musculoskeletal function and mobility

"decreased visual, auditory, and gustatory abilities" gradual loss of sight, hearing, and taste interferes with normal functioning. many medications alter GI function but do not cause decreased vision, hearing, or taste. clients are in contact with other residents and staff who provide stimulation. clients can be mobilized in wheelchairs if necessary.

a client is admitted to the telemetry unit for evaluation of reported chest pain. eight hours after admission, the client's cardiac monitor shows ventricular fibrillation. the HCP defibrillates the client. the nurse understands that the purpose of defibrillation is to do which of the following? 1. increase cardiac contractility, preload, and cardiac output 2. depolarize cells allowing SA node to recapture pacing role 3. reduce the degree of cardiac ischemia and acidosis 4. provide electrical energy for depleted myocardial cells

"depolarize cells allowing SA node to recapture pacing role" electrical current delivered to the heart depolarizes myocardial cells allowing the SA node to recapture its pacing role. all other choices are inaccurate.

the nurse is interviewing a client who is receiving treatment for OCD. Which of the following is the MOST important question for the nurse to ask this client? 1. do you find yourself forgetting simple things? 2. do you find it difficult to focus on a given task? 3. do you have trouble controlling upsetting thoughts? 4. do you experience feelings of panic in a closed area?

"do you have trouble controlling upsetting thoughts?" OCD is characterized by a hx of obsessions and compulsions. obsessions are recurrent and persistent thoughts, ideas, impulses, or images that are experienced as intrusive and senseless. the client may know that the thoughts are ridiculous or morbid but cannot stop, forget, or control them. compulsions are repetitive behaviors performed in a certain way to prevent discomfort and neutralize anxiety.

a female client visits the clinic reporting right calf tenderness and pain. it would be MOST important for the nurse to ask which of the following questions? 1. do you exercise excessively? 2. have you had any recent fractures? 3. do you take an oral contraceptive? 4. are you under a lot of stress?

"do you take an oral contraceptive?" increased risk of DVT is associated with oral contraceptives

the nurse in the postpartum unit is caring for a client who delivered her first child the previous day. while assessing the client, the nurse notices multiple varicosities in the client's lower extremities. which of the following actions should the nurse perform? 1. teach the client to rest in bed when the baby sleeps 2. encourage early and frequent ambulation 3. apply warm soaks for 20 minutes Q4H 4. perform passive ROM exercises 3x daily

"encourage early and frequent ambulation" facilitates emptying of blood vessels in lower extremities and is a preventative intervention. applying warm soaks is not a preventative intervention, it is used to treat and must be prescribed by HCP. passive ROM exercises retain joint function and maintain circulation, but early ambulation is more effective.

a client diagnosed with emphysema becomes restless and confused. which of the following steps should the nurse take first? 1. encourage pursed lip breathing 2. measure the client's temperature 3. assess the client's potassium level 4. increased O2 flow rate to 5L/min

"encourage pursed lip breathing" pursed lip breathing helps the client control the rate and depth of breathing. this client's confusion and restlessness are most likely related to poor oxygenation. measuring the client's temperature and potassium levels are unrelated to the poor oxygenation (which is related to the client's diagnosis of emphysema).

the nurse is caring for a client with cervical cancer. the nurse notes that the radium implant has become dislodged. which of the following actions should the nurse take FIRST? 1. grasp the implant with a sterile hemostat and carefully reinsert it into the client 2. wrap the implant in a blanket and place it behind a lead shield until reimplantation 3. ensure the implant is picked up with long-handled forceps and placed in a lead container 4. obtain a dosimeter reading on the client and report it to the HCP

"ensure the implant is picked up with long-handled forceps and placed in a lead container" the priority is to secure the implant to prevent unwanted and dangerous radiation exposure. the implant should be picked up with long-handled forceps and then placed in a lead container. this equipment should be kept in the room of any client receiving therapy so that it is readily available.

the home care nurse is visiting a client who delivered a newborn 2 days ago. the client states that she is bottle-feeding the newborn. the nurse notes white, curd-like patches on the newborn's oral mucous membranes. the nurse should take which of the following actions? 1. determine the newborn's blood glucose level 2. suggest that the newborn's formula be changed 3. remind the caregiver not to let the newborn sleep with the bottle 4. explain that the newborn will need to receive some medication

"explain that the newborn will need to receive some medication" thrush is white plaque on oral mucous membranes, gums, or tongue. treatment includes good handwashing and nystatin.

a nurse is caring for clients in the mental health clinic. a client reporting insomnia and anorexia tearfully tells the nurse about a personal job loss after 15 years of employment with the company. which of the following responses by the nurse would be MOST appropriate? 1. did you receive a severance package? 2. focus on your healthy, happy family 3. explain what happened with your job 4. job loss is very common these days

"explain what happened with your job" this response validates the client's concern and further explores the situation. it is an open ended question, promoting discussion.

a client admitted to the hospital with a right femur fracture is placed in balanced suspension traction with a Thomas splint and Pearson attachment. during the first 48 hours, the nurse should assess the client for which of the following complications? 1. pulmonary embolism 2. fat embolism 3. avascular necrosis 4., bone malunion

"fat embolism" fat moves into bloodstream from fracture within 24-48 hours after injury. s/sx include abnormal behavior r/t cerebral anoxia, abnormal ABG results, increased RR, chest pain, dyspnea, crackles, pallor, HTN, petechiae on chest/upper arms/abdomen. obstruction of pulmonary system by thrombus from venous system or right side of the heart occurs 2-3 days to several weeks after fracture. avascular necrosis occurs later than 48 hours after injury and is related to bone losing blood supply and dying. bone fragments healing in a deformed position as a result of inadequate reduction and immobilization (would occur much later in the healing process).

a client with a diagnosis of delirium is admitted to the hospital. blood samples are sent to the laboratory to help determine the underlying cause. laboratory test results include: sodium 156 mEq/L, chloride 100 mEq/L, potassium 4 mEq/L, bicarbonate 21 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Based on these laboratory test results, the nurse should record which of the following nursing diagnoses in the client's care plan? 1. alteration in pattens of urinary elimination 2. fluid volume deficit 3. nutritional deficit 4. self-care deficit

"fluid volume deficit" elevated sodium and BUN levels are seen with dehydration. normal sodium levels are 135-145 mEq/L. normal BUN level is 10-20 mg/dL.

during NG tube insertion, the nurse should use which of the following personal protective equipment? 1. gloves, gown, goggles, and surgical cap 2. sterile gloves, mask, and gown 3. gloves, gown, mask, and goggles 4. double gloves, goggles, mask and surgical cap

"gloves, gown, mask, and goggles" mask, eye protection, and face shield protect against mucous membrane exposure. they are used if activities are likely to generate splashes or sprays. gowns are used if activities are likely to generate splashes or sprays. surgical cap is not required for standard precautions and double-gloving is unnecessary. sterile gloves are used for sterile procedures.

the nurse is caring for clients in the outpatient clinic. a client reports weakness and numbness in the legs. the client's vital signs include BP 120/60, HR 86, RR 20. the client denies pain but appears anxious to the nurse. it would be MOST important for the nurse to ask which of the following questions? 1. have you recently fallen or suffered a physical injury? 2. have you recently had a viral infection, such as a cold? 3. have you recently taken any over-the-counter medication? 4. have you experienced any headaches over the past week?

"have you recently had a viral infection, such as a cold?" a viral infection or immunizations commonly precede GBS (symptoms: numbness and weakness in the legs, recent viral infection or immunization, anxious).

a client with a 10-year history of emphysema is admitted with a diagnosis of chronic bronchitis. the nurse should place the client in which of the following positions? 1. side lying 2. supine 3. high-fowler's 4. semi-fowler's

"high-fowler's" gravity displaces abdominal organs. high fowler's position (60-90 degrees) is used to promote cardiac and respiratory function.

a client with alcohol use disorder has been admitted to a rehabilitation unit. the nurse knows that the client is in denial about the condition when the client makes which of the following statements? 1. my brother did this to me 2. drinking always calms my nerves 3. i can stop drinking any time i feel like it 4. let's all plan to play cards tonight

"i can stop drinking any time i feel like it" denial is the unconscious refusal to admit an unacceptable idea of behavior.

a client diagnosed with anorexia nervosa is admitted to the hospital. which of the following statements by the client requires immediate follow-up by the nurse? 1. my gums bled this morning 2. i'm getting fatter every day 3. nobody likes me, i'm so ugly 4. i feel dizzy and weak today

"i feel dizzy and weak today" fluid volume deficit takes highest priority. dehydration, a common occurrence with anorexia nervosa, could lead to irreversible kidney damage and vital sign instability. vitamin deficiencies may cause bleeding gums, but are not the highest priority. body image disturbance and low self-esteem are commonly associated with this disease; however, psychosocial needs never take priority over physiological needs.

the nurse is caring for a client diagnosed with end stage colon cancer. the spouse of the client says, "we have been married for so long. i am not sure how i can go on now." what is the MOST appropriate response by the nurse? 1. it sounds like your children will be there to help during your time of grieving 2. i know this is difficult. tell me more about what you are feeling now. 3. think about the pain and suffering your spouse has endured lately 4. i will call the hospice nurse to discuss your spouse's condition with you

"i know this is difficult. tell me more about what you are feeling now" therapeutic communication. this response acknowledges the client's feelings and allows the client to express feelings (and elaborate). this is an open ended question, promoting discussion and further therapeutic communication.

a client returns to the clinic 2 weeks after hospital discharge. the client is taking warfarin sodium 2 mg PO daily. which of the following statements by the client to the nurse indicates that further teaching is necessary? 1. i have been taking an antihistamine before bedtime 2. i take aspirin whenever i have a headache 3. i put on sunscreen whenever i go outside 4. i take an antacid if my stomach gets upset

"i take aspirin whenever i have a headache" inhibits platelet aggregation and increases risk for bleeding. avoid using with warfarin. all other choices do not require intervention.

the nurse is caring for a client in the outpatient clinic with suspected AKI. the nurse would be MOST concerned if the client made which of the following statements? 1. my urine often appears pink tinged 2. it is hard for me to start the flow of urine 3. it is quite painful for me to urinate 4. i urinate in the morning and again before dinner

"i urine in the morning and again before dinner" symptoms of AKI include decreased urinary output. normal voiding pattern is 5-6 times/day and once at night. the first three symptoms are associated with UTI, not AKI.

the nurse is performing discharge teaching for a client diagnosed with chronic pancreatitis. which of the following statements by the client to the nurse indicates that further teaching is necessary? 1. i do not have to restrict physical activity 2. i should take pancrelipase before meals 3. i will eat three large meals every day 4. i need to avoid alcoholic beverages

"i will eat three large meals every day" small, frequent meals are most beneficial with chronic pancreatitis. there are no specific activity restrictions for a diagnosis of chronic pancreatitis. pancreatic enzyme replacement should be taken before or with meals. chronic pancreatitis requires complete abstinence from alcohol.

the nurse is caring for a client diagnosed with pernicious anemia. the nurse knows that teaching has been successful if the client makes which of the following statements? 1. in order to get better, i will take iron pills 2. i will attend smoking cessation classes 3. i will learn how to perform IM injections 4. i will increase my carbohydrate intake

"i will learn how to perform IM injections" pernicious anemia is caused by failure to absorb vitamin B12 because of a deficiency of intrinsic factor from the gastric mucosa. symptoms include pallor, slight jaundice, glossitis, fatigue, loss of appetite, weight loss, paresthesias of hands and feet, disturbances of balance and gait. treatment indicated is vitamin B12 IM monthly. no direct link exists between pernicious anemia and smoking. pernicious anemia is related to vitamin B12 (not iron).

the home care nurse is visiting a client with a diagnosis of hepatitis of current unknown etiology. the nurse knows that teaching has been successful if the client makes which of the following statements? 1. i am so sad that i am not able to hold my baby 2. i will eat my meal after my family finishes eating 3. i will make sure that my children don't use my eating utensils 4. i'm glad that i don't have to get help taking care of my children

"i will make sure that my children don't use my eating utensils" this client currently has hepatitis of an unknown etiology. for this reason, the client should not share eating utensils or drinking glasses, and should wash hands thoroughly before eating and after using the toilet.

the nurse is performing discharge teaching for a client diagnosed with emphysema. which statement by the client indicates the teaching was successful? 1. cold weather should help my breathing 2. i should eat 3 balanced meals daily but limit my fluid intake 3. i'll limit outside activity when pollution levels are high 4. intensive exercise should help me regain strength

"i'll limit outside activity when pollution levels are high" pollution acts as an irritant by causing bronchospasm. cold weather can exacerbate breathing problems by causing bronchospasm. small, frequent meals should be consumed to increase caloric intake and limit shortness of breath caused by eating. fluids should NOT be limited because hydration liquefies secretions. intensive exercise is not well-tolerated. a conditioning program can help increase pulmonary ventilation.

which of the following statements by a client during a group therapy session requires immediate follow up by the nurse? 1. i know i'm a chronically compulsive liar, but i can't help it 2. i don't ever want to go home; i feel safer here. 3. i don't really care if i ever see my girlfriend again 4. i'll make sure that doctor is sorry for what he said

"i'll make sure that doctor is sorry for what he said" under the Tarasoff Act, a threatened person, including HCP, must be warned about threats or potential threats to personal safety

the nurse is teaching a client about elastic stocking use, which of the following statements by the client indicates to the nurse that teaching was successful? 1. i will wear the stockings until i'm told to remove them 2. i should wear the stockings even when i am asleep 3. every 4 hours i should remove the stockings for a half hour 4. i'll put on the stockings before i get out of bed in the morning

"i'll put on the stockings before i get out of bed in the morning" elastic stockings promote venous return by applying external pressure on the veins. they should be applied in the morning because this is the time of day that the legs are usually the least swollen. the client should remove the stockings daily for bathing and to inspect extremities. stockings are not necessary during prolonged periods of sleep (client can elevate the leg on a pillow while sleeping to promote venous return). stockings should be worn when client is out of bed to promote venous return.

the home care nurse is visiting a client during the icteric phase of hepatitis of unknown etiology. the nurse would be MOST concerned if the client made which of the following statements? 1. i must not share eating utensils with my family members 2. i must use my own bath towel 3. i'm glad i can have intimate relations with my partner 4. i must eat small, frequent meals

"i'm glad i can have intimate relations with my partner" the client with hepatitis of unknown etiology should avoid sexual contact until serologic indicators return to normal. hepatitis A (high risk: young children, institutions for custodial care, international travelers) is transmitted through fecal/oral and poor sanitation. hepatitis B (high risk: IV drug users, homosexually active men, transfusions, mother-baby) is transmitted through parenteral, sexual contact, blood/bodily fluids. hepatitis C (high risk: IV drug users, transfusions, international travelers) is transmitted through blood/bodily fluids.

which of the following statements by a client during a group therapy session would the nurse identify as reflecting a client's narcissistic personality disorder? 1. i'm sick of hearing about all your life tragedies 2. i know i'm interrupting others. so what! 3. i just can't stop wanting to slash myself 4. i currently have no real hope for the future

"i'm sick of hearing about all your life tragedies" clients with narcissistic personality disorder lack empathy. the second option is more characteristic of antisocial personality disorder (prominent behavior). the third option is more characteristic of antisocial personality disorder. the fourth option is a characteristic of depression.

the nurse is planning discharge teaching for a client with Parkinson's disease. to maintain safety, the nurse should make which of the following suggestions to the family? 1. install a raised toilet seat 2. obtain a hospital bed 3. instruct the client to hold arms dependently during ambulation 4. participate in an exercise program during the late afternoon

"install a raised toilet seat" a raised toilet seat helps the client maintain independence. there are no indications for a hospital bed. the client should swing their arms to maintain balance when walking. activities should be scheduled for the late morning when energy levels peak.

the nurse is caring for a client one day after an abdominal-perineal resection for rectal cancer. the nurse should question which of the following prescriptions? 1. remove NG tube if audible bowl sounds 2. irrigate colostomy 3. cover the stoma site with petrolatum gauze 4. administer meperidine 50 mg IM for postoperative pain

"irrigate colostomy" colostomy irrigation should not be performed immediately after surgery when the colostomy is not yet functioning. the colostomy commonly begins to function 3-6 days after surgery. audible bowel sounds usually indicate the return of peristalsis, an indication for the removal of NG tube. petrolatum gauze may be used to cover the stoma and keep the stoma moist if there is not a pouch in place. meperidine is an opioid analgesic that can effectively relieve postoperative pain.

the nurse is leading an inservice about management issues. the nurse would intervene if another nurse made which of the following statements? 1. it is my responsibility to ensure the signed consent form is in the client's medical record before the surgical procedure 2. it is my responsibility to witness the signature of the client on the consent form before the surgical procedure 3. it is my responsibility to provide a detailed description of the surgical procedure 4. it is my responsibility to answer client questions prior to the surgical procedure

"it is my responsibility to provide a detailed description of the surgical procedure" it is the primary HCP's legal responsibility to explain the procedure in detail (the nurse is simply a witness to the signature, then records it in the EMR).

a client is telling the nurse about personal thought patterns. which of the following statements by the client would validate the diagnosis of schizophrenia? 1. i can't get the same thoughts out of my head 2. i sometimes feel on top of the world, and then suddenly down 3. sometimes i look up and wonder where i am 4. it's clear that this is an alien laboratory and i am in charge

"it's clear that this is an alien laboratory and i am in charge" schizophrenia is generally characterized by delusions (grandiose, religious, paranoid, nihilistic, or delusions in reference of influence), confusion, hallucinations, and illusions (misinterpretations of real external stimuli). this client's personal thought patterns are also illogical and disorganized, which are typical of schizophrenia

a parent calls the well-baby clinic to report upper respiratory infection (URI) symptoms and fever of 104F in an infant scheduled to receiving diphtheria, tetanus, and pertussis (DTaP) vaccine and inactivated polio vaccine (IPV) later that day. the parent asks whether the infant should still receive the scheduled immunizations. which of the following responses by the nurse would be the most appropriate? 1. keep the infant home. we'll give a double dose next time 2. bring the infant in. the infant's illness will not interfere with the immunizations 3. keep the infant home until the fever and infection resolve 4. bring the infant in. we'll give an antibiotic with the immunizations

"keep the infant home until the fever and infection resolve" immunization is contraindicated during infectious or inflammatory state, pre-existing symptoms could mask adverse or allergic reaction. febrile illness is a contraindication for immunizations.

which of the following actions by the nurse would be considered negligence? 1. obtaining a blood sample for Gurthrie blood testing on a 4-day-old client 2. massaging gently the abdomen of a 3-year-old client with a Wilm's tumor 3. instructing a 5-year-old client with asthma to blow on a pinwheel 4. playing kickball with a 10-year-old client with juvenile-onset arthritis

"massaging gently on the abdomen of a 3-year-old with a Wilm's tumor" negligence is the unintentional failure of the nurse to perform an act that a reasonable person would or would not perform in similar circumstances (can be an act of commission or omission). manipulation of mass may cause dissemination of cancer cells.

the nurse is caring for clients in a pediatric clinic. the mother of a 14-year-old male privately tells the nurse that she is worried about her son because she unexpectedly walked into his bedroom and discovered his masturbating. which of the following responses by the nurse would be MOST appropriate? 1. tell your son he could go blind doing that 2. masturbation is a normal part of sexual development 3. he's really too young to be masturbating 4. why don't you give him more privacy?

"masturbation is a normal part of sexual development" this answer is both non-judgmental and appropriate. masturbation provides opportunity for (healthy) sexual self-exploration

the nurse is teaching a client how to breastfeed her newborn. the nurse knows that teaching has been successful if the client makes which of the following statements? 1. my baby's weight should equal the birth weight in 5-7 days 2. my baby should have at least 6-8 wet diapers per day 3. my baby will sleep at least 6 hours between feedings 4. my baby will feed for about 10 minutes per feeding

"my baby should have at least 6-8 wet diapers per day" this indicates newborn is adequately hydrated and ingesting adequate nutrition. breastfed infants should surpass birth weight in 10-15 days. newborns feed approximately every 2-3 hours during the day and every 4 hours at night. the newborn should feed for about 15-20 minutes per breast.

the nurse is discharging a client from an inpatient alcohol treatment unit. which of the following statements by the client's family member indicates to the nurse that the family member is coping adaptively? 1. he will do well if i keep him engaged in his favorite activities 2. my focus is learning how to live my life 3. i am glad that our problems are behind us 4. i'll make sure that the children don't give him any problems

"my focus is learning how to live my life" the family member is working to change (adapting) codependent patterns. other options have codependent or avoidant nature.

the nurse is admitting a client with a history of pancreatic cancer who appears jaundiced. the nurse should give the HIGHEST priority to which of the following needs? 1. nutrition 2. self image 3. skin integrity 4. urinary elimination

"nutrition" profound weight loss and anorexia occur with pancreatic cancer. these are the most pressing symptoms that the nurse must prioritize. a client who appears jaundiced may be concerned about personal appearance, but physiological needs take priority. jaundice causes dry skin and pruritus; scratching can lead to skin breakdown. the obstructive process caused by pancreatic cancer darkens urine; kidney function is not affected.

the school nurse notes that a child is scratching the head almost constantly. it would be MOST important for the nurse to take which of the following actions? 1. discuss basic hygiene with the parents 2. instruct the child not to sleep with the dog 3. advise the parents to contact an exterminator 4. observe the scalp for small white specks

"observe the scalp for small white specks" pediculosis (lice) assessment includes white eggs (nits) on hair shafts that are itchy. assess first!

the nurse knows that the plan of care for a client with severe liver disease should include which of the following actions? 1. administer sodium polystyrene sulfonate enemas 2. offer a low-protein, high-carbohydrate diet 3. insert a Sengsteken-Blakemore tube 4. offer a high-fat, high-sodium diet

"offer a low-protein, high-carbohydrate diet" protein breakdown increases ammonia levels in severe liver disease, thereby increasing the risk for hepatic coma. fat and sodium are restricted with advanced liver disease. sodium polystyrene sulfonate enemas decrease serum potassium levels, not ammonia levels associated with severe liver disease. a sengsteken-blakemore tube is used to apply pressure against bleeding esophageal varices (which are often found with liver disease) to tamponade bleeding.

to determine the structural relationship of one hospital department with another, the nurse should consult which of the following? 1. organizational chart 2. job descriptions 3. personnel policies 4. procedures manual

"organizational chart" the lateral lines on an organizational chart define the division and specializations of labor. the vertical lines explain the lines of authority and responsibility.

a client is admitted with diagnoses of DVT and PE. a continuous heparin infusion is prescribed. five days after receiving the infusion continuously, which finding MOST concerns the nurse? 1. potassium level increases from 4-5 mEq/L 2. the client states, "i just found out that i'm pregnant" 3. platelet count drops to 135,000 4. aspartate aminotransferase (AST) level 20 U/L

"platelet count drops to 135,000" this is indicative of heparin induce thrombocytopenia (HIT). priority is to discontinue heparin therapy. hyperkalemia is an adverse affect of heparin therapy, but this value is WDL. heparin does not cross the placenta but should only be used when potential benefits outweigh potential risks. should notify HCP of client's report of pregnancy, but not highest priority. AST levels are WDL.

a client is admitted who reports severe pain in the right lower quadrant of the abdomen. which of the following actions should the nurse take to assist the client with pain relief? 1. encourage rhythmic, shallow breathing 2. massage the lower right quadrant of the abdomen 3. apply a warm heating pad to the client's abdomen 4. position the client for comfort using pillows

"position the client for comfort using pillows" non-phamacological method of pain relief. do not massage or apply heating pad until r/o appendicitis (could cause appendix to rupture).

the nurse is caring for a client receiving parenteral nutrition through a CVAD. the nurse notices a small trickle of opaque fluid leaking from the dressing. which of the following actions is MOST important for the nurse to take? 1. prepare to immediately change CVAD dressing 2. verify that the client is prescribed abx 3. position the client's head lower than the feet 4. secure the Y-port where the lipids are infusing

"position the client's head lower than the feet" a trickle of fluid indicates catheter breakage or disconnection, which places the client at risk for air embolism. turn the client on the left side and position the head lower than the feet. notify HCP. dressing should be removed later to further assess the situation, but this is not the most important action. there is no evidence of a CLABSI. fluid is leaking from the IV site, not the Y site (so securing the Y-port wouldn't fix the problem).

the nurse plans care for a client diagnosed with anemia who reports weakness. which of the following tasks should the nurse assign to the UAP? 1. auscultate the client's breath sounds 2. set up the client's lunch tray 3. obtain the client's dietary history 4. instruct the client how to balance rest and activity

"set up the client's lunch tray" UAP assist with direct client care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital signs/height/weight/I&O, housekeeping, transporting, stocking supplies. setting up the client's lunch tray is a standard, unchanging procedure. helping the client with this will decrease the client's cardiac workload.

a client is brought to the emergency department reporting chest pain. the nurse assesses the client. which of the following symptoms would be MOST characteristic of an acute MI? 1. intermittent, localized epigastric pain 2. sharp, localized, unilateral chest pain 3. severe substernal pain radiating down the left arm 4. sharp, burning chest pain moving from place to place

"severe substernal pain radiating down left arm" pain may be crushing, radiating. it is unrelated to emotion or exercise. intermittent localized epigastric pain indicates GI disorder. sharp localized unilateral chest pain indicates possible pneumothorax. sharp burning chest pain that moves from place to place may be caused by anxiety.

a client comes into the emergency department reporting sudden onset of severe right flank pain. while awaiting the results of the prescribed CT scan, it is MOST important for the nurse to take which of the following actions? 1. make sure that the client does not eat or drink anything 2. strain the client's urine through several layers of gauze 3. check the client's grip strength and pupils for reactivity 4. send blood and urine specimens for laboratory analysis

"strain the client's urine through several layers of gauze" symptoms are suggestive of renal calculi and require urine straining to monitor for the passage of stones. sending the specimens for laboratory analysis are not most important for suspected renal calculi.

during the acute phase of a stroke, the nurse should maintain the client in which of the following positions? 1. semi-prone with the HOB elevated 60-90 degrees 2. lateral, with HOB flat 3. prone, with HOB flat 4. supine, with HOB 30-45 degrees

"supine, with HOB 30-45 degrees" facilitates venous drainage from the brain, reduces ICP, and keeps head in midline position.

the home care nurse is planning care for a school-age client in a leg cast for treatment of a right ankle fracture. the nurse enters the following nursing diagnosis on the care plan: skin integrity- risk for impaired. which of the following actions by the nurse is BEST? 1. teaching the client how to perform isometric exercises of the right leg 2. teaching the parent to gently massage the client's right foot with moisturizer 3. instructing the parent to keep the leg cast clean and dry 4. teaching the parent how to turn and reposition the client

"teaching the client how to perform isometric exercises to the right leg" contraction of muscle without moving the joint promotes venous return and circulation, prevents thrombi. exercises include quadriceps setting (push back knees into bed) and gluteal setting (push heels back into bed).

the nurse is caring for a primipara client in labor who is 4 cm dilated and 25% effaced, and whose fetal vertex is at +1. the primary health care provider informs the client that an amniotomy is needed. the client states, "my friend's baby died when the umbilical cord came out when her water broke. i don't want you to do that to me!" which of the following responses by the nurse is BEST? 1. if you are concerned, you should refuse the procedure 2. the procedure will help your labor progress more quickly 3. that shouldn't happen to you because the baby's head is engaged 4. we will monitor you carefully to prevent cord prolapse

"that shouldn't happen to you because the baby's head is engaged" an amniotomy is the artificial rupture of membranes. the presenting part should be engaged to prevent cord prolapse (cord prolapse only happens when the fetus is NOT engaged, and monitoring would not help in this situation). obtain fetal HR before and after procedure. assess color, odor, consistency of amniotic fluid. check maternal temperature Q2H and notify provider if temperature rises to 100.4F.

the nurse is helping an unlicensed assistive personnel (UAP) provide a bed bath to a comatose client who is incontinent. the nurse should intervene if which of the following actions is noted? 1. the UAP answers the phone while wearing gloves 2. the UAP log-rolls the client to provide back care 3. the UAP places an incontinence pad under the client 4. the UAP positions the client on the left side, with the HOB elevated

"the UAP answers the phone while wearing gloves" contaminated gloves should be removed and discarded, and then hand hygiene performed before answering the phone. this is part of standard precautions.

the nurse is teaching an elderly client with right-sided weakness how to use a cane. which of the following behaviors by the client indicates that the teaching was effective? 1. the client holds the cane with the right hand, moves the cane forward followed by the right leg, and then moves the left leg 2. the client holds the cane with the right hand, moves the cane forward followed by the left leg, then moves the right leg 3. the client holds the cane with the left hand, moves the cane forward followed by the right leg, then moves the left leg 4. the client holds the cane with the left hand, moves the cane forward followed by the left leg, and then moves right leg

"the client holds the cane in the left hand, moves the cane forward followed by the right leg, then moves the left leg" the cane acts as a support and aids in weight-bearing of the weaker right leg. left hand (strong side), right leg (weak, is being supported extra by cane), left leg (strong side).

the nurse is teaching an elderly client how to use a pick-up aluminum walker. which of the following behaviors by the client indicates that the nurse's teaching was effective? 1. the client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker 2. the client lifts the walker, moves it forward 10 inches, and then takes several small steps forward 3. the client supports weight on the walker while advancing forward, then takes small steps while balancing on the walker 4. the client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance

"the client lifts the walker, moves it forward 10 inches, and then takes several small steps forward" the client should pick up the walker, and then place it down on all legs. the client should not support weight on the walker while trying to move it. the client should not slide or push the walker forward (should pick it up and place it down in a sturdy fashion).

the client diagnosed with major depressive disorder who was admitted to the psychiatric unit for treatment and observation a week ago suddenly appears cheerful and motivated. the nurse should be aware of which of the following? 1. the client is likely sweeping well bc of the medication 2. the client has made new friends and has a support group 3. the client may have finalized a suicide plan 4. the client is no longer depressed due to treatment

"the client may have finalized a suicide plan" clients emerging from severe depression have more energy with which to formulate and carry out a suicide plan. the nurse should determine risk for suicide.

the nurse is caring for a client who had a thyroidectomy 6 hours ago for treatment of Graves' disease. the nurse would be MOST concerned if which of the following was observed? 1. the client's vital signs include BP 132/82, HR 84, RR 16 2. the client supports the head and neck to turn head to right 3. the client spontaneously flexes the wrist when the blood pressure cuff is inflated during blood pressure measurement 4. the client becomes drowsy and reports a sore throat

"the client spontaneously flexes the wrist when the blood pressure cuff is inflated during blood pressure measurement" carpal spasms indicate hypocalcemia. this is one of the complications of a thyroidectomy (due to decreased calcium from parathyroid involvement).

the nurse is supervising the care of a client receiving parenteral nutrition through a single-lumen central venous access device (CVAD). the nurse would be MOST concerned if which of the following was observed? 1. the client receives insulin through the single lumen CVAD 2. a mask is placed on the client during the site dressing change 3. the client's dressing is changed daily using sterile technique 4. the client is weighed 2-3 times per week in the morning

"the client's dressing is changed daily using sterile technique" transparent semi-permeable dressing is changed every 5-7 days (unless soiled).

a client is brought to the emergency department for treatment after being found on the floor by a family member. x-rays reveal a displaced subcapital fracture of the left hip. when comparing the legs, the nurse would most likely make which of the following observations? 1. the client's left leg is shorter than the right leg and externally rotated 2. the client's left leg is longer than the right leg and internally rotated 3. the client's left leg is shorter than the right leg and adducted 4. the client's left leg is longer than the right leg and is abducted

"the client's left leg is shorter than the right leg and externally rotated" affected leg externally rotates and shortens due to contraction of muscles attached above and below fracture site. fragments overlap by 1-2 inches.

a 1-day-old client diagnosed with intrauterine growth retardation has a high-pitched, shrill cry and appears restless and irritable. the nurse also observes fist-sucking behavior. based on this data, which of the following actions should the nurse take FIRST? 1. gently massage the client's back 2. tightly swaddle the client in a flexed position 3. schedule feeding times every 3-4 hours 4. encourage eye contact with the client during feedings

"tightly swaddle the client in flexed position" drug withdrawal may manifest from 12 hours to 10 days after delivery. symptoms include high pitched cry, hyperreflexia, decreased sleep, diaphoresis, tachypnea, excessive mucus production, vomiting, uncoordinated sucking. tightly swaddling the infant will promote comfort and security. massaging and eye contact may overstimulated the client. scheduling feeding at small and frequent intervals is preferable to Q3-4H.

which of the following actions by the nurse would be considered negligence? 1. inserting a 16 Fr nasogastric tube and aspirating 15 mL of gastric contents 2. administering meperidine 50 mg IM to a client prior to using the incentive spirometer 3. turning and repositioning a client every shift after post-abdominal surgery 4. initially administering a blood transfusion at 2 mL per minute for 15 minutes

"turning and repositioning a client every shift after post-abdominal surgery" negligence is the unintentional failure of the nurse to perform an act that a reasonable person would or would not perform in similar circumstances (can be an act of commission or omission). postoperative clients should be turned and repositioned Q2H after surgery to promote circulation and reduce risk of skin breakdown (except if contraindicated, such as in neurologic or musculoskeletal surgery demanding immobilization).

the nurse is teaching a client who is scheduled for a paracentesis. which of the following statements by the client to the nurse indicates that teaching has been successful? 1. i will be in surgery for less than an hour 2. i must not void prior to the procedure 3. two or three liters of fluid will be removed 4. i will lie on my side and breathe slowly

"two or three liters of fluid will be removed" HCP slowly removes 2-3L of fluid to decrease ascites (in severe cases, can remove up to 6L). this is not a surgical procedure. bladder must be emptied prior to the procedure to prevent accidental puncture. for this procedure, the client is positioned upright with feet supported or supine.

the nurse is caring for a client 4 hours after intracranial surgery. which of the following actions should the nurse take immediately? 1. instruct the client to deep breathe, cough, and expectorate into a tissue 2. position the client in a left lateral position with the neck flexed 3. perform passive range-of-motion exercises Q2H 4. use a turning sheet under the client's head to midthigh to reposition client in bed

"use a turning sheet under the client's head to midthigh to reposition client in bed" using a turning sheet under the client's head to midthigh helps move the client as a unit maintaining body alignment, and reducing the risk for increased ICP. DB&C, positioning the head away from midline, and performing passive ROM exercises all have potential to increase ICP.

the nurse prepares a client for peritoneal dialysis. which of the following actions should the nurse take FIRST? 1. assess access for bruit and thrill 2. warm the dialysate solution 3. position client on left side 4. insert an indwelling urinary catheter

"warm the dialysate solution" peritoneal dialysis takes place within the peritoneal cavity to remove excess fluids and waste products usually removed by the kidneys. warming the dialysate solution (via warmer or with heating pad, NOT in the microwave) promotes comfort. assessment of bruit/thrill is used in hemodialysis (with fistula, graft, or shunt access). the client should be in supine or low Fowler's position and wearing a mask. a urinary catheter is unnecessary.

the nurse is caring for a client who reports an off-white vaginal discharge with a curd-like appearance. the nurse observes the discharge and vulvular erythema. it would be MOST important for the nurse to ask which of the following questions? 1. do you have diabetes insipidus? 2. are you sexually active? 3. what kind of birth control do you use? 4. do you take cough medicine?

"what kind of birth control do you use?" vaginal candidia albicans infection symptoms include odorless, cheesy white discharge, itching, inflammation of vagina and perineum. oral contraceptive use predisposes individuals to candidiasis.

the nurse visits a neighbor who is at 20 weeks' gestation. the neighbor reports nausea, headache, and blurred vision. the nurse notes that the neighbor has tremors and appears nervous and diaphoretic. it would be MOST important for the nurse to ask which of the following questions? 1. are you having menstrual-like cramps? 2. when did you last eat or drink? 3. have you been diagnosed with diabetes mellitus? 4. have you been lying on the couch?

"when did you last eat or drink" irritability, confusion, tremors, blurring vision, coma, seizures, hypotension, tachycardia, skin tool and clammy, and diaphoresis are all presentations of hypoglycemia.

the nurse is caring for a client at 37 weeks' gestation who has a history of type one diabetes mellitus. the client states, "i am so thrilled that i will be breastfeeding my baby." which of the following responses by the nurse is BEST? 1. you will probably require less insulin while you breastfeed 2. you will initially require more insulin after the baby is born 3. you will be able to take an oral anti-diabetic agent instead of insulin after the baby is born 4. you will likely require the same dose of insulin that you require now

"you will probably require less insulin while you breastfeed" during the last trimester, insulin requirements increase due to increased insulin resistance. after the baby is born, postpartum physiological changes and breastfeeding will have an antidiabetogenic effect and insulin need will decrease. breastfeeding has an anti-diabetic effect, requiring less insulin. the client has type 1 DM, a condition that requires insulin.

the nurse is caring for a client hospitalized for observation after a fall. the client states, "my friend fell last year, and no one thought anything was wrong. she died 2 days later!" which of the following responses by the nurse is BEST? 1. this happens to quite a few people 2. we are monitoring you, so you'll be okay 3. don't you think i'm taking good care of you? 4. you're concerned that it might happen to you?

"you're concerned that it might happen to you?" this response reflects the clients feelings. the therapeutic communication technique of repetition to clarify is used.

a client is admitted to the hospital for treatment of pneumocystis jiroveci pneumonia and Kaposi's sarcoma 2/2 to HIV. the client informs the nurse about a personal decision to become an organ donor. which of the following responses by the nurse is BEST? 1. what does your family think about your decision? 2. you will help many people by donating your organs 3. would you like to speak to the organ donor coordinator? 4 your illness prevents you from becoming an organ donor

"your illness prevents you from becoming an organ donor" clients with documented HIV are prohibited from donating organs.