Nclex review- 4

The physician orders sucralfate (Carafate) 1 g PO bid for a client taking digoxin (Lanoxin) 0.25 mg daily. The client asks the nurse if both pills can be taken together at breakfast so that the client doesn't forget to take them. The nurse should advise the client to take which of the following actions? 1. Take the Carafate and Lanoxin before breakfast. 2. Take the Lanoxin 1 hour before breakfast and the Carafate 1 hour after breakfast. 3. Take the Carafate 1 hour before breakfast and the Lanoxin 1 hour after breakfast. 4. Take the Carafate and the Lanoxin after breakfast.

(1) Carafate forms a barrier on the gastrointestinal mucosa, would decrease absorption of other medications, separate by 2 hours (2) Carafate best results on empty stomach (3) correct—Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption (4) Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption ...

The nurse observes care given to a client experiencing severe to panic levels of anxiety. The nurse should intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.

(1) appropriate nursing action for this level of anxiety (2) appropriate nursing action for this level of anxiety (3) correct—at this level of anxiety, client is unable to process thoughts and feelings for problem solving (4) appropriate nursing action for this level of anxiety ...

The nurse recognizes which of the following as a positive response to fluoxetine HCl (Prozac)? 1. The nurse notes hand tremors and leg twitching. 2. The client states that he is able to sleep for longer periods of time. 3. The client has an increased energy level and participates in unit activities. 4. The nurse observes that the client is hypervigilant and scans the environment.

(1) can be side effect of the medication (2) not an effect of Prozac, can actually inhibit sleep; is useful with clients who experience increased sleeping and psychomotor retardation and lethargy (3) correct—fluoxetine HC (Prozac) is an "energizing" antidepressant; as client begins to demonstrate a positive response, he has an increased energy level, is able to participate more in milieu (4) can be side effect of medication ...

An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter. An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.

(1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges (2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent (3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity (4) caused by subcutaneous bleeding, common during first few exchanges ...

A 2-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which of the following as a priority nursing action? 1. Report the findings to the child protection agency. 2. Share this information only with other health care professionals. 3. Document this information in the chart. 4. Share the information with the pediatric social worker.

(1) correct—any suspicion of child abuse should be reported to the child protection agency (2) does not provide or plan for protection of the child (3) does not provide or plan for protection of the child (4) does not provide or plan for protection of the child

A client comes to the health clinic and tells the nurse that the client has taken acetaminophen (Aspirin-Free Excedrin) daily for 5 months. The nurse is MOST concerned by which of the following lab results? 1. AST (SGOT) 30 units/L, ALT (SGPT) 27 units/L. 2. Hgb 16.2 g/dL, Hct 46%. 3. WBC 7,000/mm3. 4. BUN 9 mg/dL.

(1) correct—can cause liver damage, normal AST (formerly SGOT) 8 to 20 units/L, normal ALT (formerly SGPT) 8 to 20 units/L (2) normal Hgb male 13.5-17.5 g/dL, female 12-16 g/dL, normal Hct male 41 to 53%, female 36 to 46% (3) normal WBC 5,000 to 10,000/mm3 (4) normal BUN 7 to 18 mg/dL

The nurse knows which of the following observations is indicative of chronic cocaine use? 1. Nasal septum disruption. 2. Lack of coordination. 3. Constricted pupils. 4. Craving for sweets and carbohydrates.

(1) correct—chronic inhalation creates sores, burns, disruption of mucous membranes, and holes in the nasal septum (2) barbiturate abusers typically suffer from lack of coordination (3) narcotic abusers demonstrate constricted pupils (4) clients who abuse marijuana, hashish, and/or THC experience cravings for sweets and carbohydrates ...

The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with his mouth. 2. The client places a battery-powered device against the side of his neck. 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips.

(1) correct—describes esophageal speech (2) describes electric larynx (3) method of speech for patient with a tracheostomy (4) describes tracheoesophageal fistula (TEF) ...

The nurse cares for a 26-year-old woman immediately after delivery of 8-lb, 4-oz baby girl. The patient's history indicates that she was diagnosed with type 1 diabetes at age 12. The nurse expects which of the following changes to occur in the patient? 1. The blood sugar will fall because of a sudden decrease in insulin requirements. 2. The blood sugar will rise because of a rapid decrease in circulating insulin. 3. The blood sugar will gradually rise because of a decreased level of metabolic stress. 4. The blood sugar will gradually fall because of a decrease in food intake.

(1) correct—hormonal interference in glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery (2) blood sugar will fall after delivery (3) blood sugar level will fall after delivery (4) fall in blood sugar not primarily caused by decrease in food intake

A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy setup. 4. Suction equipment.

(1) correct—hypokalemia is not expected after this surgery (2) used to treat tetany resulting from possible damage to parathyroid glands (3) essential equipment to provide for airway (4) needed to maintain a patent airway ...

When administering antipsychotic medications parenterally, the nurse should take which of the following actions? 1. Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. 2. Caution the client not to drink or operate machinery that requires mental alertness for safety. 3. Have an emergency cart available in case of an adverse reaction. 4. Reassure the client that side effects are only temporary.

(1) correct—primary concern with postural hypotension caused by medication and preventing an injury from a fall; monitoring vital signs will provide data to address this concern (2) not relevant with this classification of medications (3) not relevant with this classification of medications (4) not relevant with this classification of medications ...

Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe. 2. Limit fluid intake. 3. Supply a high-carbohydrate diet. 4. Evaluate skin integrity.

(1) correct—represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations due to the abdominal incision (2) fluids should be encouraged (3) will not prevent complications (4) does not address a common complication...

The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which of the following clients? 1. A client who had a total hip replacement and requires assistance with ambulation. 2. A client with type I diabetes mellitus who has bilateral 4+ pitting edema of the feet. 3. A client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine. 4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder.

(1) correct—stable patient with expected outcome (2) requires the assessment skills of the RN (3) requires assessment and teaching (4) requires assessment skills of RN ...

When assisting with a bone marrow aspiration, the nurse should take which of the following actions? 1. Drop additional sterile supplies onto a sterile tray. 2. Unwrap all sterile packs for the procedure in case they are needed. 3. Reach over the tray, and remove contaminated supplies. 4. Place the bottle of sterile liquid on the sterile field so that it does not splash.

(1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area (2) sterile packs should be opened only as needed (3) never reach an unsterile arm over a sterile field (4) outside of a bottle containing sterile liquid is not considered to be sterile ...

Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain? 1. Remove the dressing layers one at a time. 2. Clean the wound with Betadine solution and hydrogen peroxide. 3. Clean the drain area first. 4. If the dressing adheres to the wound, pull gently and firmly.

(1) correct—to avoid dislodging drain, remove the dressing layers one at a time (2) do not clean a wound with both Betadine solution and hydrogen peroxide (3) cleansing of the wound is from the center outward to the edges and from the top to the bottom (4) incorrect; may dislodge drain ...

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement.

(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program (2) not of primary importance in designing an effective behavior modification program (3) not of primary importance in designing an effective behavior modification program (4) not of primary importance in designing an effective behavior modification program

The nurse supervises the staff caring for four clients receiving blood transfusions. Which of the four clients should the nurse see FIRST? 1. A client complaining of a headache. 2. A client vomiting. 3. A client complaining of itching. 4. A client with neck vein distention.

(1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin (2) correct—hemolytic reaction; most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and renal perfusion (3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give Benadryl, and administer oxygen (4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen ...

A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."

(1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication

The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster? 1. A 19-year-old with a broken tibia in Buck's traction. 2. A 50-year-old with a diabetic foot ulcer. 3. A 62-year-old heart transplant with suspected rejection. 4. An 84-year-old with chronic obstructive pulmonary disease.

(1) has an acute trauma, is not immunocompromised (2) has a bacterial infection, is not immunocompromised (3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus (4) has chronic disease, is not immunocompromised ...

A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions? 1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing. 2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air. 3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry. 4. Soak in a warm tub three times a day, and rub the spots with a washcloth.

(1) if lesions are open and draining, they must be cleaned and dressed daily to prevent secondary infection (2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma (3) correct—important to keep the skin clean and prevent secondary skin infection (4) increases risk of secondary skin infection ...

The nurse cares for a child several hours after the application of a hip spica cast. The patient turns on the call light and complains of pain in the left foot. Which of the following actions should the nurse take FIRST? 1. Elevate the left leg on two pillows. 2. Palpate the cast for warmth and wetness. 3. Administer pain medication as ordered. 4. Check the blanching sign on both feet.

(1) implementation; done to prevent swelling and venous congestion, not helpful to reduce pain due to circulatory impairment (2) assessment; not helpful to reduce pain due to circulatory impairment, should not palpate wet cast, would result in depressions causing pressure (3) implementation; pain important diagnostic symptom, should not be suppressed or masked (4) correct—assessment; pain main symptom of circulatory impairment from cast; pressing nail of great toe indicates circulatory function, compare speed with which color returns with result on the opposite side; sluggish return indicates circulatory impairment, too rapid return indicates venous congestion ...

The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload? 1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. 2. Cool skin, respiratory crackles, pulse 86 and bounding. 3. Complaints of a headache, abdominal pain, and lethargy. 4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus.

(1) indicates dehydration (2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement (3) symptoms could be from causes other than volume overload (4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen

The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends." The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends."

(1) involves forced expiration; would not cause problems with asthma (2) correct—main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves (3) school activities should be encouraged to help development (4) walking is good exercise; running could be a problem if he has exercise-induced asthma

A client who is positive for human immunodeficiency virus (HIV) is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST? 1. Review the importance of adhering to a 4-hour schedule. 2. Advise the client to buy a timed pill dispenser. 3. Write the schedule of when the medicine should be taken. 4. Encourage self-medication prior to discharge.

(1) less helpful in the overall teaching-learning process (2) less helpful in the overall teaching-learning process (3) correct—planned and written schedule of administration is more effective for adherence to time frames (4) less helpful in the overall teaching-learning process ...

The nurse counsels an elderly client who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which of the following about the client? 1. The client has an anal fixation resulting from recent loss of a spouse. 2. The client is depressed because of alterations in intestinal absorption and excretion. 3. The client is experiencing excessive concern with body function because of physical changes. 4. The client has regressed because of a fear of losing the ability to have bowel movements.

(1) makes judgment without information (2) constipation common finding in elderly; no information about depression (3) correct—physical changes occur in late adulthood causing changes in body image; constipation frequent problem of elderly, but reaction by this client is excessive (4) no information provided about regression ...

After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?"

(1) may be part of follow-up (2) correct—means of transmission of chlamydia may or may not have been made clear to both partners; nurse should assess this first; is a sexually transmitted disease (3) most cultures used today have few false positives (4) would be done later in the nursing assessment

A client is in cardiogenic shock after a myocardial infarction (MI). Which of the following is a correctly stated nursing diagnosis for the client? 1. Activity intolerance: related to impaired oxygen transport. 2. Altered tissue perfusion related to decreased heart-pumping action. 3. Altered cardiac output related to cardiac ischemia. 4. Potential fluid volume deficit related to decreased intake.

(1) not best (2) correct—correctly stated, appropriate nursing diagnosis (3) altered cardiac output is not a commonly accepted nursing diagnosis (4) not appropriate for this client ...

The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. Signs and symptoms of infection. 2. Fluid and electrolyte balance. 3. Seizure precautions. 4. Steroid replacement.

(1) not most important (2) not most important (3) not most important (4) correct—steroid replacement is the most important information the client needs to know ...

The nurse cares for clients in the emergency department of an acute care facility. Four clients have been admitted during the previous 10 minutes. Which of the following admissions should the nurse see FIRST? 1. A client complaining of chest pain that is unrelieved by nitroglycerine. 2. A client with full-thickness burns to the face. 3. A client with a fractured hip. 4. A client complaining of epigastric pain.

(1) not the highest priority; airway most important (2) correct—face, neck, chest, or abdominal burns result in severe edema, causing airway restriction (3) airway is most important (4) requires further assessment; airway is a priority

The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1. The nurse restrains an agitated, confused patient in the emergency room with a physician's order. 2. The nurse chases a patient who tries to run away while outside for a walk. 3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance. 4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison.

(1) restraining a client to prevent injury to self or others is appropriate (2) appropriate behavior (3) restraining a client to prevent injury to self or others is appropriate (4) correct—battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is psychotic

The nurse administers morphine 6 mg IV push to a patient for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via face mask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside.

(1) should be given Narcan for low respiratory rate (2) problem is low respirations; this may be administered after medication (3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action (4) unnecessary

An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to the client by the nurse? 1. "Take the medication on a full stomach or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for 2 weeks."

(1) should be taken on an empty stomach (2) correct—photosensitivity occurs with the use of this medication (3) should be taken as directed (4) unnecessary ...

The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions? 1. Use a new, sterile catheter each time the client performs a catheterization. 2. Perform the Valsalva maneuver before doing the catheterization. 3. Perform the catheterization procedure every 8 hours. 4. Limit oral fluids to reduce the number of times a catheterization is needed.

(1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder (2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization (3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours (4) should encourage fluids...

Which of the following is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms? 1. Collect the specimen 30 minutes after the child falls asleep at night. 2. Save a portion of the child's first stool of the day and take it to the physician's office immediately. 3. Collect the specimen in the early morning with a piece of Scotch tape touched to the child's anus. 4. Feed the child a high-fat meal, and then save the first stool following the meal.

(1) specimen should be collected early in the morning after the child awakens (2) unnecessary; pinworms are not routinely found in the stool (3) correct—pinworms crawl outside the anus early in the morning to lay their eggs (4) inappropriate for this situation ...

A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? 1. The child places his head close to the table when drawing. 2. The child rubs his eyes frequently. 3. The child closes one eye to see a poster on the wall. 4. The child is unable to see objects in the periphery of his visual field.

(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range (2) suggestive of refractive error (3) correct—visual axes are not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision

The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis? 1. Tenderness at the IV site. 2. Increased swelling at the insertion site. 3. Reddened area or red streaks at the site. 4. Leaking of fluid around the IV catheter.

(1) tenderness at the IV site is common (2) increased swelling at the insertion site may indicate infiltration (3) correct—characterized by inflammation and reddened areas around site and up length of vein (4) not indicative of phlebitis ...

The RN makes nursing assignments for the burn unit. Which of the following indicates the MOST appropriate assignment for a client with a positive cytomegalovirus (CMV) titer? 1. A nurse with an upper respiratory infection. 2. A young nurse who is 8 weeks pregnant. 3. A male nurse who is CMV-negative. 4. An older nurse with 30 years of experience.

(1) those with a cytomegalovirus-positive titer are often immunosuppressed clients who should be protected from other pathogens (2) CMV is fetotoxic; should inform client of risks (3) this nurse is at increased risk for developing the disease (4) correct—most appropriate option due to decreased risk ...

The nurse should explain to a client that glipizide (Glucotrol) is effective for diabetics who 1. can no longer produce any insulin. 2. produce minimal amounts of insulin. 3. are unable to administer their injections. 4. have a sustained decreased blood glucose.

(1) type 1 insulin-dependent diabetic is unable to produce insulin (2) correct—oral hypoglycemic agents are administered to type 2 (non-insulin-dependent) clients who are able to produce minimal amounts of insulin (3) type 1 diabetics who cannot administer their injections need alternate plans to be made for them to receive the injection from a family member (4) Glucotrol is administered for an increase in blood glucose

The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following? 1. Limited adduction of the right leg. 2. Uneven gluteal fold and thigh creases. 3. Increase in length of the right limb. 4. Internal rotation of the right leg.

(1) will see limited abduction (2) correct—folds and creases will be longer and deeper on affected side (3) will be decrease in limb length (4) may or may not see internal rotation

Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position the client on the abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist the client with heat application and ROM exercises.

(1) would result in contractures due to the strength of flexor muscles (2) should encourage range of motion in all joints, not just hip flexors (3) massaging inflamed joints will add to inflammation and pain (4) correct—reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility ...

A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. re-establishes a trusting relationship with his/her other parent. 3. verbalizes that he/she is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.

.(1) continues the myth of "badness" and that he/she deserved the abuse and actively consented to it (2) outcome that would be positive but usually is not an initial result of treatment (3) correct—victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse" (4) expected outcome ..

A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements? 1. The catheter can be removed during the day. 2. External catheters are uncomfortable. 3. The catheter would drain into a bag at the bedside or on the wheelchair. 4. The external condom catheter is easy to apply.

.(1) correct—being free from any drain bags during the day would appeal to a 13-year-old (2) is negative (3) would be embarrassing to a 13-year-old (4) it would be impossible for a teen with muscular weakness to put on an external catheter ..

An elderly client returns from surgery after a hysterectomy due to cancer, and there is an order for antiembolism stockings. Which of the following should the nurse include when instructing the client about wearing the support stockings? 1. "Wear the stockings when your legs cramp." 2. "Wear the stockings during your hospitalization." 3. "Put the stockings on prior to going to bed." 4. "Put the stockings on after you get out of bed in the morning."

...Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antiembolism stockings should be worn to prevent any discomfort and to increase the blood flow (2) correct—stockings should be worn the entire time that client is in the hospital; should be removed for baths and replaced after the skin is dry, and before the client gets out of bed (3) stockings should be worn during the day and when client is nonambulatory (4) stockings should be applied before getting out of bed

The nurse identifies which of the following is MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment? 1. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups. 2. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking. 3. Tell the family that it is not their fault that the client behaves inappropriately. 4. Involve the family in the assessment of the client when he/she is first admitted to the hospital.

1) correct—this group provides ongoing support and educational information; people who attend have common needs and goals focused on managing the clients' behavior at home (2) would be helpful but will not have the ongoing impact of the support group (3) would be helpful but will not have the ongoing impact of the support group (4) would be helpful but will not have the ongoing impact of the support group

The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? 1. "The poison control center number is stored on all the phones in our house." 2. "I should induce vomiting if my child swallows lighter fluid." 3. "If I carry medication in my purse, it should be in a child-proof container." 4. "Proper storage is the key to poison prevention in the home."

Strategy: "Further teaching is necessary" indicates an incorrect statement. (1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions (2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets

A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed? 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. Diaphoresis and trembling. 4. Headache and polyuria.

Strategy: "MOST concerned" indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia

A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h."

Strategy: "Question which of the following orders" indicates an incorrect order. (1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers

The nurse in the outpatient clinic instructs a client diagnosed with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective? 1. The client advances the cane 18 inches in front of the foot with each step. 2. The client holds the cane in the left hand. 3. The client advances the right leg, then the left leg, and then the cane. 4. The client holds the cane with elbows flexed 60°.

Strategy: "Teaching is effective" indicates a correct behavior. (1) should advance cane 6-10 inches with body weight on both legs (2) correct—should hold cane on strong side, widens base of support, reduces stress on affected side (3) should advance cane, weaker leg, stronger leg (4) should flex no more than 30°

The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following? 1. Atropine sulfate (Atropine) IV. 2. Isoproterenol (Isuprel) IV. 3. Verapamil (Calan) IV. 4. Lidocaine hydrochloride (Xylocaine) IV.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antidysrhythmic, used for bradycardia (2) antidysrhythmic, used for heart block, ventricular dysrhythmias (3) antihypertensive, calcium-channel blocker (4) correct—lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client should recline for 30 minutes after eating (2) fluids should be given between meals (3) intake of carbohydrates should be reduced along with highly spiced foods (4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates

The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—contact precautions required for diapered or incontinent clients (2) do not remove toys from room, possibly contaminated (3) diet should be high in carbohydrates and protein and low in fat (4) contact precautions required in addition to standard precautions

An adult client has regular insulin ordered before breakfast. The nurse notes that the client's blood glucose level is 68 mg/dL and the client is nauseated. Which of the following actions should the nurse take? 1. Immediately give the client orange juice to drink. 2. Administer the insulin on time. 3. Withhold the insulin, and notify the physician. 4. Return the breakfast tray to the kitchen.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may cause vomiting (2) correct—take insulin or oral agent as ordered, check blood glucose or urine ketones every 3 to 4 hours, sip 8 to 12 oz liquid per hour, substitute easily digested soft foods, liquids if solids not tolerated (3) blood glucose increases during illness; even though client can't eat, administer insulin (4) does not address the client's problem

The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician. 2. Inform surgery. 3. Contact the father to obtain consent. 4. Continue the child's preoperative preparation.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to notify the physician (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent or legal guardian required to give informed consent prior to surgical procedure

The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for 6 to 9 months.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) on airborne precautions during hospitalization; can send home with family because they are already exposed (2) not required (3) important, but not as important as taking medication (4) correct—necessary to take medication for 6 to 9 months

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes. 2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing. 3. The nurse packs wet gauze into the incision without overlapping it onto the skin. 4. The old dressing is saturated with sterile saline before it is removed.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should clean from the center of wound to the outside using sterile equipment (2) dressings should be soaked before application (3) correct—if wet dressing touches skin, it could cause skin breakdown (4) should be removed dry so that wound debris and necrotic tissue are removed with old dressing

Prochlorperazine maleate (Compazine) 10 mg IM is ordered for a client. The client is also to receive butorphanol (Stadol) 2 mg IM. Before administering these medications, the nurse should take which of the following actions? 1. Obtain respirations and temperature. 2. Dilute with 9 ml of NS. 3. Draw the medications in separate syringes. 4. Verify the route of administration.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority (2) inappropriate (3) correct—Compazine should be considered incompatible in a syringe with all other medications (4) unnecessary

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. Wash the burn with an antiseptic soap and water. 2. Remove clothing, and wrap the victim in a clean sheet. 3. Leave the blisters intact and apply an ointment. 4. Take no action until the victim arrives in a burn unit.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) soaps and ointments should not be applied to second-degree burns in an emergency situation (2) correct—after fire is out, remove clothing and cover victim with a clean sheet (3) soaps and ointments should not be applied to second-degree burns in an emergency situation (4) does not prevent infection

The nurse's INITIAL priority when managing a physically assaultive client is which of the following? 1. Restrict the client to the room. 2. Place the client under one-to-one supervision. 3. Restore the client's self-control and prevent further loss of control. 4. Clear the immediate area of other clients to prevent harm.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) time out or room restriction might be a useful strategy before the client becomes assaultive; once client is assaultive, he/she may continue this behavior in his/her room without any redirection and support (2) may not stop assaultive behavior (3) correct—most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client's self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client (4) is helpful but may not be realistic if the situation escalates quickly

After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tube would be irrigated with normal saline after the position of the tube was evaluated (2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4 (3) does not assess status of nasogastric tube (4) does not assess status of nasogastric tube

A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following? 1. Prepare to administer IV Pitocin to the client. 2. A reduction in the amount of pain medication administered. 3. Check the client's blood pressure every 5 minutes. 4. Prepare an isolette for the infant.

Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention. (1) uterine contractions not affected by MS (2) correct—less pain medication is required because of overall decrease in pain perception due to MS (3) no reason to assess this frequently (4) baby's outcome not affected by MS ...

The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. Talk with the client about how the client is feeling. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now

The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client's BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate? 1. Obtain a pulse oximetry reading. 2. Apply soft wrist restraints. 3. Reorient the client to person and place. 4. Determine the client's blood glucose level.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; symptoms indicate reduced oxygen levels (2) implementation; must assess first to determine problem; all other interventions must be tried before using restraints (3) implementation; must determine the cause of the behavior before implementing (4) assessment; symptoms indicate decreased oxygen levels

The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? 1. "That must have been a real shock to you." 2. "You should be tested for hepatitis B." 3. "You'll receive the hepatitis B immune globulin (HBIG)." 4. "Have you had unprotected sex with your boyfriend?"

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) nurse is interjecting own feelings (2) will require testing; not best response initially (3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine (4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implement

A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations. (1) correct—implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid (2) implementation; clients are not placed in the prone position (3) implementation; bed rest is maintained for several hours after the test (4) assessment; an extremity was not used for injection of the dye

The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh. 2. Perform resistive range of motion of the left leg. 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. Standard precautions. 2. Testing for HIV. 3. Transfer to an acute care nursery facility. 4. Request AZT from the pharmacy.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—provides immediate protective care for the staff members (2) might be employed, safety is the priority (3) might be employed, is not a priority (4) this medication is not used in infancy ...

In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following? 1. Teach the child to read and write. 2. Teach the child sex education at home. 3. Give the child responsibility around the house. 4. Expect stormy behavior.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may require some assistance from the parents, but children this age learn at their own rate (2) unnecessary at this early age (3) correct—giving children responsibilities allows them to develop feelings of competence and self-esteem through their industry (4) does not occur until about age 11

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer oxygen. 2. Turn her to the right side. 3. Provide adequate hydration. 4. Start antibiotics.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not a priority (2) not a priority (3) correct—adequate hydration is a priority for any client with sickle cell crisis (4) not a priority

The nurse cares for an elderly client diagnosed with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unrealistic (2) correct—irreversible disease that leads to permanent physical limitations (3) unnecessary; disease usually is not terminal (4) unrealistic; disease is progressive, cannot be arrested

If a client develops cor pulmonale (right-sided heart failure), the nurse expects to observe which of the following? 1. Increased respiration with exertion. 2. Cough producing large amount of thick, yellow mucus. 3. Peripheral edema and anorexia. 4. Twitching of extremities.

Strategy: Determine how each answer choice relates to cor pulmonale. (1) common assessment finding of the patient with chronic lung disease (2) describes a complication of pneumonia (3) correct—right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema; also, there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites (4) is not seen with this client...

A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says that she feels pressure against her diaphragm when the baby moves.

Strategy: Determine how each answer choice relates to pregnancy. (1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency (2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities (3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored (4) not unusual, due to pressure of enlarging uterus

A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.

Strategy: Determine if each answer relates to increased ICP. (1) normal for the first year of life (2) correct—high-pitched cry is one of the first signs of an increase in the intracranial pressure in infants (3) fontanelle should be closed by the third month (4) with increased pressure, the pupil may respond to light slowly, rather than with the usual brisk response

The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum.

Strategy: Determine the cause of each answer choice and how it relates to Pronestyl. (1) procainamide is given to treat premature ventricular contractions or atrial tachycardia (2) correct—severe hypotension or bradycardia are signs of an adverse reaction to this medication (3) procainamide is given to treat premature ventricular contractions or atrial tachycardia (4) lab value is within normal limits

The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST? 1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift. 2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week. 3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab. 4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.

Strategy: Determine the least stable situation (1) important issue that needs to be addressed after tending to the client who is bleeding (2) patients take priority over personnel issues (3) can be delegated to another staff member (4) correct—should assess client to determine amount and cause of bleeding

The nurse cares for clients in the antepartal clinic. A client at 34 weeks' gestation comes to the clinic for treatment of a sprained ankle. The nurse should question which of the following orders? 1. ASA (aspirin) 650 mg PO q4h prn for pain. 2. Return to the clinic in 2 weeks. 3. Apply ice to sprain for 20 minutes qh for 24 hours. 4. Teach client three-gait crutch walking.

Strategy: Determine the outcome of each answer choice. Is it desired? (1)correct—aspirin can cause fetal hemorrhage; do not use during pregnancy (2) routine follow-up (3) treat sprain with rest and elevation of affected part; intermittent ice compresses for 24 hours (4) appropriate gait if client unable to bear weight

The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum.

Strategy: Determine the significance of each answer choice and how it relates to scoliosis. (1) correct—thoracic area becomes noticeably distorted (2) seen with hip dislocation (3) seen with circulatory or inflammatory processes (4) seen with pigeon breast, or pectus carinatum

An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of heart failure (HF), is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is MOST important for the nurse to assess for which of the following? 1. Sticky mucous membranes; decreased urinary output; and firm, rubbery tissues. 2. Cool, moist skin; fine hand tremors; and mental confusion. 3. Headache, apprehension, and lethargy. 4. Shortness of breath, chest pain, and anxiety.

Strategy: Determine the significance of each answer choice. (1) symptoms of hypernatremia, along with restlessness, weakness, coma, tachycardia, flushed skin, oliguria, fever (2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (3) correct—symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin (4) symptoms of CHF, chest x-ray clear, no other information provided

The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages? 1. 5 months of age. 2. 6 months of age. 3. 9 months of age. 4. 12 months of age.

Strategy: Picture each infant. (1) unable to sit unsupported until 8 months (2) unable to sit unsupported until 8 months (3) correct—can pull self up and assume a sitting position at 8 months, can say few words (4) would be able to say three to five words in addition to dada and mama

A client takes gemfibrozil (Lopid) 600 mg PO bid. It is MOST important for the nurse to monitor which of the following? 1. Serum creatine. 2. Erythrocyte sedimentation rate (ESR). 3. Aspartate aminotransferase (AST) (or formerly SGOT). 4. Arterial blood gases (ABG).

Strategy: Recall what each lab function is measuring and determine how it relates to gemfibrozil (Lopid). (1) indicates renal function, normal 0.6 to 1.2 mg/dL (2) indicates inflammation, normal 0 to 20 mm/h (3) correct—indicates liver function, normal 8-20 units/L; lipid-lowering agent used with patients with high serum triglyceride levels, side effects include abdominal pain, cholelithiasis; take 30 minutes before breakfast and supper (4) indicates acid/base balance...

A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? 1. Head of bed elevated 30-45°. 2. Head of bed elevated 60-90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side.

Strategy: Remember the positioning strategy. (1) head of bed not elevated enough (2) correct—facilitates swallowing and movement of tube through gastrointestinal tract (3) not the best position (4) not the best position

A client diagnosed with AIDS is seen in the emergency room with complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following? 1. Metronidazole (Flagyl) 7.5 mg/kg q6h. 2. Ketoconazole (Nizoral) 200 mg daily. 3. Trimethoprim-sulfamethoxazole (Bactrim) 800 mg PO q12h. 4. Rifampin (Rifadin) PO 10 mg/kg daily.

Strategy: The topic of the question is unstated. (1) anti-infective, used in treatment of intestinal amebiasis, trichomoniasis, inflammatory bowel disease (2) correct—drug of choice for treatment of candidiasis (3) treatment for PCP; symptoms of dyspnea, tachypnea, persistent dry cough, fever, fatigue (4) treatment for tuberculosis; symptoms of fever, chills, night sweats, weight loss, anorexia

A 4-month-old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis, a lumbar puncture (LP) is ordered. While assisting the physician with the procedure, it is MOST important for the nurse to take which of the following actions? 1. Appropriately restrain the child. 2. Instruct the parents about the procedure. 3. Provide support to the child. 4. Elevate the head of the bed.

Strategy: Think "Maslow." (1) correct—primary objective is to prevent trauma to child during the procedure; child must be restrained (2) not as high a priority as preventing injury to the child (3) should be done before and/or after the procedure (4) elevating the head of the bed for a 4-month-old will not expose the spinal column ...

Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage peers to visit on a regular basis.

Strategy: Think "Maslow." (1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety is a priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority ...

The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following? 1. Encourage the client to verbalize feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Help the client identify and mobilize resources and support systems.

Strategy: Think "Maslow." (1) psychosocial, priority is physical injury (2) correct—physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client's physiologic integrity is maintained (3) psychosocial, done concurrently as the nurse is assessing for physical injury (4) psychosocial, priority is physical injury

Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.

Strategy: Think about each answer choice. (1) inaccurate for the situation (2) incorrectly stated (3) incorrectly stated (4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients

A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following? 1. If a fever does occur in a child after a DPaT, it usually occurs within the first 2 hours. 2. An elevated temperature is very rarely seen in a child after a DPaT immunization. 3. If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours. 4. The child's high fever is a direct response to the DPaT immunization and should be treated.

Strategy: Think about each answer choice. (1) inaccurate; low-grade fever is expected within 24 to 48 hours (2) inaccurate; low-grade fever is expected within 24 to 48 hours (3) correct—low-grade fever and irritability frequent response to immunization (4) symptoms should be reported to physician, antipyretic usually prescribed

After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), the nurse notes a decrease in muscle tone. The nurse determines which of the following nursing diagnoses is priority? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes.

Strategy: Think about each answer choice. (1) not a priority (2) correct—leading cause of skin breakdown is a decrease in tissue perfusion (3) not a priority (4) would be more relevant to right-sided hemiparesis ...

A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. "I have been helping my family deal with their feelings about the surgery." 2. "I have been having difficulty coping with the surgery and cry frequently." 3. "I have been unable to leave the house or talk to my friends about the surgery." 4. "I am doing just great since the surgery and have gone back to work at my job."

Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation? (1) will not be able to help others this soon after surgery (2) correct—normal reaction 1 month later (3) excessive, abnormal reaction (4) indicates integration, too early for this stage

After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.

Strategy: Think about how each answer choice relates to a head injury. (1) not priority (2) correct—indicates a rupture of meninges and presents a potential complication of meningitis (3) not priority (4) is not a change in assessment

A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient? 1. Oxycodone terephthalate (Percodan). 2. Ibuprofen (Motrin). 3. Enteric-coated aspirin. 4. Codeine phosphate (Paveral).

Strategy: Think about the action of each medication. (1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (4) correct—analgesic used for moderate to severe pain

Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin? 1. Severe cravings, depression, fatigue, hypersomnia. 2. Depression, disturbed sleep, restlessness, disorientation. 3. Nausea and vomiting, tachycardia, coarse tremors, seizures. 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea.

Strategy: Think about the cause of each symptom and how it relates to narcotic withdrawal. (1) describes cocaine withdrawal (2) describes amphetamine withdrawal (3) describes barbiturate withdrawal (4) correct—narcotic withdrawal is very much like the symptoms of the flu