NCLEX Review
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
Cold intolerance. Explanation: Cold intolerance may be associated with anemia because of the diminished oxygen supply to the peripheral circulation. Decreased salivation is not necessarily associated with anemia. Tachycardia may be expected in severe anemia. Clients with anemia are usually not nauseated.
A client with a history of cardiac problems complains of severe chest pain. What should be the nurse's first response? a) apply oxygen 2L/min via nasal cannula b) assess client's pain c) notify physician d) administer analgesic
b- assess pain first
A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and doesn't respond to verbal or tactile stimuli. In formulating nursing care interventions, the nurse should give priority to:
observing and evaluating the client's nutritional needs.
A nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
one fingerbreadth below umbilicus. After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis.
The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate?
"Every person is different. What works for one client may not always be effective for another." Explanation: The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings.
A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which of the following statements indicates the client has adequate knowledge?
"I will dilute the medication and drink it with a straw."- Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth. Iron causes constipation, not diarrhea. It is normal for the client's stools to become dark during iron therapy. Iron does not cause bleeding gums.
A 2 year old is brought to the emergency department following a seizure. The child currently has the flu and has had fevers for the last 3 days. The father asks what caused the seizure. The nurse's best response is:
"The seizure likely occurred because your child's temperature rose beyond a personal threshold."
The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which of the following equipment does the nurse need to perform the injection?
27 gauge needle and 1 inch needle
Where is the best place for a nurse to detect fetal heart sounds for a client in the first trimester of pregnancy?
Above the symphysis pubis Explanation: In the first trimester, fetal heart sounds are loudest in the area of maximum intensity, just above the client's symphysis pubis at the midline. Fetal heart sounds aren't heard as well below the symphysis pubis, above the umbilicus, or at the umbilicus.
At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate?
Altered tissue perfusion related to effects of anaesthesia
A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She doesn't have transportation. How can the nurse help this client be compliant with her care?
Ask the clinic case manager to speak with the client.
Which of the following factors would most likely contribute to the development of a client's hiatal hernia?
Being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg). Explanation: Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than in men. Having a sedentary desk job, using laxatives frequently, or being 40 years old is not likely to be a contributing factor in development of a hiatal hernia.
A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client?
Decreasing environmental stimulation Explanation: This client is at increased risk for injuring himself or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. If this nursing intervention is ineffective, the nurse may administer a sedative, as ordered. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, involving him in unit activities is contraindicated.
When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first?
Document her findings. Explanation: The nurse must first document her assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. She must follow the chain of command. The nurse isn't a manager or supervisor and may not have the authority to administer discipline. Although it might be appropriate for the nurse to make an incident report, she doesn't yet have adequate information to prepare a complete report.
The heart rate of a just-born term neonate is regular at 142 bpm. Which of the following should the nurse do next?
Document this as a normal neonatal finding. Explanation: Normally, a neonate's heart rate should be between 120 and 160 bpm shortly after birth. The nurse should document this as a normal neonatal finding. The physician does not need to be notified. Assessing for cyanosis is a routine assessment at birth, but with the neonate's heart rate at 142 bpm, cyanosis should be minimal and typically located in the hands and feet. Heart rate assessments are performed routinely according to facility protocol. For example, the heart rate is assessed soon after birth, every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then every 4 hours
Which plane divides the body longitudinally into anterior and posterior regions?
Frontal plane Explanation: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
Which of the following lab values should the nurse report to the health care provider when the client has anemia?
Intrinsic factor, absent. Explanation: The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B cannot be absorbed in the small intestine and folic acid needs vitamin B for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.
The nurse is preparing to assist with the removal of a chest tube. Which of the following is appropriate at the site from which the chest tube is removed?
Petroleum gauze. Explanation: Gauze saturated with petroleum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dressings with antibiotic ointment or adhesives are not used.
A client received magnesuim sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate?
Respiratory depression Explanation: Magnesium sulfate crosses the placenta. Potenial neonatal effects include respiratory depression, hypotonia, and bradycardia. The serum blood glucose isn't affected by magnesium sulfate. The neonate would likely be floppy, not jittery.
A client with type 1 diabetes takes 15 units of Humulin N insulin before breakfast and 8 units before dinner. During a follow-up visit, the nurse reevaluates the client's knowledge about insulin therapy and self-administration skills. The nurse realizes the client requires additional teaching when she discovers the client takes which over-the-counter preparations?
The client requires additional teaching if he takes salicylates with insulin. Salicylates may interact with insulin, causing hypoglycemia. Antacids, vitamins with iron, and acetaminophen aren't known to interact with insulin
The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information is most important to communicate to the physician?
The client's daily record indicates a 3 kg weight gain over 2 days.
A client with acute bronchitis is admitted to the health care facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?
The oxygen tubing is pinched. Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.
When developing the plan of care for a child with early Duchenne's muscular dystrophy, which of the following nursing goals is the priority?
The primary nursing goal is to maintain function in unaffected muscles for as long as possible. There is no effective treatment for childhood muscular dystrophy. Children who remain active are able to forestall being confined in wheelchair. Remaining active also minimizes the risk for social isolation. Preventing rather than encouraging wheelchair use by maintaining function for as long as possible is an appropriate nursing goal. Children with muscular dystrophy become socially isolated as their condition deteriorates and they can no longer keep up with friends. Maintaining function helps prevent social isolation. Circulatory impairment is not associated with muscular dystrophy
Sodium polystyrene sulfonate (Kayexalate) is prescribed for a client following crush injury. The drug is effective if:
The serum potassium is 4.0 meq/liter (4/0 mmol/l). Explanation: Following crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate (Kayexalate) is a potassium-binding resin. The resin combines with potassium in the colon and is then eliminated. Serum potassium levels should return to normal. Normal serum potassium values are between 3.5 and 5.2 meq/liter (3.5 to 5.2 mmol/l). Weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.
The mother asks the nurse about using a car seat for her toddler who is in a hip spica cast. The nurse should tell the mother
The toddler in a hip spica cast needs a specially designed car seat. The one that the mother already has will not be appropriate because of the need for the car seat to accommodate the cast and abductor bar.
A 10-year-old child is taking high doses of aspirin. Which of the following indicate the child is experiencing early salicylate toxicity?
dizziness
The most appropriate site for a nurse to use to administer an I.M. injection to a 2-year-old child is the:
vastus lateralis (preferred) ventrogluteal (2nd preferred)
The most appropriate site for a nurse to use to administer an I.M. injection to a 2-year-old child is the:
ventrogluteal muscle. Explanation: When administering an I.M. injection to a 2-year-old child, the nurse might select the ventrogluteal muscle if the muscle is well developed. However, the preferred site is the vastus lateralis. The pectoral, femoral, and deltoid muscles aren't appropriate injection sites for a child.
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in his discharge teaching?
• Providing humidity at home. • Learning how to suction himself. • Having communication rehabilitation with a speech pathologist • Attending a smoking cessation program. Explanation: Home care for a client with a total laryngectomy should include a high-humidity environment, laryngectomy tube care and suctioning, speech rehabilitation, and smoking cessation. The client is not restricted to a bland diet.
After a child returns from the postanesthesia care unit after surgery, which of the following should the nurse assess first?
After surgery, the nurse's initial assessment is the surgical site dressing to determine whether there is any bleeding or drainage. Once this assessment is completed, then the nurse would assess the other areas such as the I.V. access site, pain, and nasogastric tube function.
A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?
Children with iron-deficiency anemia are more susceptible to infection than are other children. Explanation: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.
The adrenal cortex is responsible for producing which substances?
Glucocorticoids and androgens
A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?
Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse. Explanation: The nurse should wrap an appropriate-size cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can't palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mm Hg. Having the client lie down, inflating the cuff to at least 200 mg, and taking blood pressure readings in both of the client's arms aren't appropriate measures.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain?
Intermittent with knees drawn to the chest.
A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
breast sensitivity
A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:
4 hours. Explanation: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.
A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. A subculture is best described as which of the following?
A unique cultural group that exists within the larger culture.
Which of the following laboratory tests should be monitored closely by the nurse while the client is receiving heparin therapy?
Activated partial thromboplastin time (APTT). Explanation: APTT is used to measure the clotting status when the client is receiving heparin. The INR is used to measure clotting status in a client receiving warfarin. Prothrombin time (PT) is used to measure clotting status in a client receiving warfarin. Neither heparin nor warfarin affects thrombin time.
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern?
Bradycardia Explanation: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity
When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse should place the first priority on discussing the use of which of the following?
Child restraints in automobiles. Explanation: Motor vehicle injuries are the leading cause of death in children older than 1 year of age. Most fatalities are related to nonuse of child restraints and seat belts. Although using helmets for biking and skating safety is important, it is not the priority. Special locks for cabinets are important in the prevention of poisoning, but this is not the priority. Topical bug repellant in summer is important for the prevention of Lyme disease. However, this is not the priority.
When caring for a client with trigeminal neuralgia, which intervention has the highest priority?
Encouraging the client to bathe with care Explanation: Trigeminal neuralgia is a common disorder that causes severe pain along the trigeminal nerve (the nerve affecting the face) and surrounding areas. The nurse should encourage to the client to be gentle when bathing because performing facial hygiene can cause pain. The client's facial appearance doesn't change, so it isn't necessary to provide emotional support for changes in physical appearance. The nurse doesn't need to make monitoring intake and output and assisting with ambulation priorities because these parameters aren't affected by disorders of the trigeminal nerve.
A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
Facial erythema, pericarditis, pleuritis, fever, and weight loss Explanation: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.
A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
Fat. Explanation: Breast milk has a higher fat content than cow's milk. Thirty percent to 55% of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
Flulike symptoms- Interferon alfa-2b (Intron A) most commonly causes flulike adverse effects, such as myalgia, arthralgia, headache, nausea, fever, and fatigue. Retinopathy is a potential adverse effect, but not a common one. Diarrhea may develop as an adverse effect. Clients are advised to administer the drug at bedtime and get adequate rest. Medications may be prescribed to treat the symptoms. The drug may also cause hematologic changes; therefore, laboratory tests such as a complete blood count and differential should be conducted monthly during drug therapy. Blood glucose laboratory values should be monitored for the development of hyperglycemia.
A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first?
Formally report her concerns to the nurse-manager. Explanation: A nurse who identifies issues involving quality of care must follow the chain of command. Although there may be a need for an investigation, the nurse shouldn't initiate one without discussion with the nurse-manager. Charts should be reviewed after a formal investigation is established. The nurse's responsibilities include identifying and reporting issues and concerns involving client care.
A 3 year old is recovering from a concussion. The persistence of which finding is least concerning?
Inability to hop. Explanation: The inability to hop is not concerning, because it is a milestone for a 4 year old, not a 3 year old. Lack of interest in toys, changes in eating habits, and increased temper tantrums that persist for several weeks all require an evaluation by a neurologist or other specialist.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift Explanation: Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be to
Take the neonate's blood pressure in all four extremities. Explanation: The next nursing action would be assessing blood pressure in all four extremities and comparing the findings. A difference of 15 mm Hg in systolic blood pressure between the arm and legs indicates a narrowed aorta. This could be an emergency, and the primary health care provider must be notified as soon as blood pressure data have been collected. Generally, ordering a consult is not a nursing function. Placing the neonate in the reverse Trendelenburg position will only decrease perfusion to the lower extremities.
While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and bathroom. In which order of priority from first to last should the nurse take the following actions? a) Assess the client's current condition and vital signs. b) If the client shows no signs of acute injury, get help and carefully assist the client back to bed. c) Document as required by the facility. d) Notify the client's physician and family.
a, b, d, c
A nurse should question an order for a heating pad for a client who has:
active bleeding
Why should the nurse avoid palpating both carotid arteries at one time?
bradycardia
When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to:
develop respiratory infections easily
Nursing assessment reveals that a client has paradoxical chest expansion. Such expansion is best described as:
lung movement outward during expiration and inward during inspiration. Explanation: In paradoxical chest expansion, the lungs move outward during expiration and inward during inspiration. The client may exhibit signs of ineffective gas exchange, such as tachypnea (an abnormally fast respiratory rate), secondary to a paradoxical breathing pattern.
A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
peripheral edema. Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.
A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about:
recent streptococcal infection. Explanation: A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction.
A client has just undergone a lumbar puncture. Which finding should the nurse immediately report to the physician?
A moderate amount of serous fluid was noted on the lumbar dressing.
The nurse observes the client instill eyedrops. The client says, "I just try to hit the middle of my eyeball so the drops don't run out of my eye." The nurse explains to the client that this method may cause:
Corneal injury. Explanation: The cornea is sensitive and can be injured by eyedrops falling onto it. Therefore, eyedrops should be instilled into the lower conjunctival sac of the eye to avoid the risk of corneal damage. The drops do not cause scleral staining or excessive lacrimation. Systemic absorption occurs when eyedrops enter the tear ducts.
The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which vaccine order would the nurse question?
Measles, mumps, and rubella (MMR). Explanation: The MMR is a live vaccine. Neither the American Academy of Pediatrics nor the Public Health Agency of Canada recommends routine vaccination with the MMR (either alone or combined with the varicella vaccine) to children younger than 12 months. The DTaP, Hib, and Hep B are all indicated.
A client being treated for iron deficiency anemia with ferrous sulfate continues to be anemic despite treatment. The nurse should assess the client for use of which medication?
Aluminum hydroxide - The nurse should assess the client for possible use of antacids such as aluminum hydroxide. Clients should take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption
Which of the following nursing interventions does not aid in meeting the goal of clear breath sounds? a) monitoring breath sounds b) early ambulation c) providing a minimum of 1500 mL of fluids/day d) design a vigorous exercise program
c) - should be 2500 mL of fluids/day
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
12 months. Explanation: A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy
A client at 28 weeks' gestation in premature labor was placed on nifedipine (Procardia). To maintain the pregnancy, the primary health care provider orders the client to have 20 mg now, followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 0600? (Type in a single-digit answer only.)
8 Explanation: If 10 mg were administered at 10:00 a.m. and 12:00 p.m. and then 20 mg were administered at 4:00 p.m., 8:00 p.m., 10:00 p.m., 12:00 a.m., 4:00 a.m., and 8:00 a.m., the dose at 8:00 a.m. reached the maximum oral dose of 120 mg/day.
Which finding from a laboratory report is most indicative of aplastic anemia?
A decreased hemoglobin. Explanation: A decreased hemoglobin is indicative of aplastic anemia. In addition to a decreased hemoglobin and red blood cell count, the client will also have a decreased white blood cell count and decreased platelets. The white blood count is decreased, not elevated. The red blood count is decreased, not elevated. Erythrocyte sedimentation rates are elevated in the presence of inflammation and may be elevated in anemia.
A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum?
Ask the physician for an order to obtain cultures of both of the neonate's eyes. Explanation: Ophthalmia neonatorum, caused by Neisseria gonorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge isn't normal in a 1-day-old neonate. Neisseria gonorrhea is caused by a gram-negative bacteria, not by a virus.
When teaching a primigravid client with diabetes about common causes of hyperglycemia during pregnancy, which of the following would the nurse include?
Maternal infection. Explanation: Maternal infection is the most common cause of maternal hyperglycemia and can lead to ketoacidosis, coma, and death. The client should notify the primary health care provider immediately if she experiences symptoms of an infection. Fetal macrosomia, obesity before conception, and pregnancy-induced hypertension are not associated with maternal hyperglycemia during pregnancy.
A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should:
Notify the physician. Explanation: ICP is highest in the early morning, and the client with hydrocephalus may be experiencing signs of increased ICP that need to be treated. The increased ICP is not related to fluid levels, and the nurse should not advise the client to increase fluid intake. While ICP does fluctuate during the day, it is highest in the morning and the nurse should notify the physician. Pain medication will not treat the potentially increasing ICP and may mask important signs of increasing ICP.
When developing the plan of care for a client with aplastic anemia, which of the following goals would be most appropriate for the nurse to include?
Perform activities of daily living without excessive fatigue or dyspnea. Explanation: With aplastic anemia, measures to conserve energy and reduce oxygen requirements are key. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B12 in the diet. However, vitamin B12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate.
A nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is:
Benztropine, trihexyphenidyl, or amantadine are ordered for treatment of Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms
The primary health care provider orders mirtazapine (Remeron) 30 mg P.O. at bedtime for a client diagnosed with depression. The nurse should:
Give the medication as prescribed. Explanation: The nurse should give the medication as prescribed. Mirtazapine is given once daily, preferably at bedtime to minimize the risk of injury resulting from postural hypotension and sedative effects. The usual dosage ranges from 15 to 45 mg. There is no reason to question the primary health care provider's prescriptions. The nurse should administer the medication as prescribed. Requesting to give the medication in three divided doses is inappropriate and demonstrates the nurse's lack of knowledge about the drug.
The client who had an open femoral fracture was discharged to the home and developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings?
Osteomyelitis. Explanation: Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.
The nurse walks into a client's room to administer the 9:00 a.m.(0900) medications and notices that the client is in an awkward position in bed. What is the nurse's first action?
Straighten the client's pillow behind his back. Explanation: The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his name and checking his armband, so that the medication can be administered.
A client's catheter is removed 4 days after a transurethral resection of the prostate (TURP). He is experiencing urinary dribbling. Which one of the following nursing interventions is appropriate in this situation?
Teach the client Kegel exercises. Explanation: After TURP, sphincter tone is poor, resulting in dribbling or incontinence. Kegel exercises can increase sphincter tone and decrease dribbling. Voiding every hour will not prevent dribbling or improve sphincter tone. It may take up to 12 months for urinary continence to be regained.
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
Temperature. Explanation: Premature rupture of the membranes is commonly associated with chorioamnionitis, or an infection. A priority assessment for the nurse to make is to document the client's temperature every 2 to 4 hours. Temperature elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection. The red blood cell count would provide information related to anemia, not infection. The client is not in labor. Therefore, assessing the degree of discomfort is not a priority at this time. Urinary output is not a reliable indicator of an infection such as chorioamnionitis.
An elderly client is admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the physician should include what recommendations? Select all that apply. • Fluid restriction. * 2 g sodium diet • Bed alarm. • Encourage fluids. • Foley catheter. • Vital signs every 4 hours instead of every shift. • Repeat electrolytes, urine for sodium and specific gravity in the morning. • Strict intake and output.
fluid restriction, bed alarm, foley, vital signs, repeat labs, strict I & O. Encouraging fluids and restricting dietary sodium to 2 g may further exacerbate the hyponatremia.
Laboratory results for a child with a congenital heart defect with decreased pulmonary blood flow reveal an elevated hemoglobin (Hb) level, hematocrit (HCT), and red blood cell (RBC) count. These data suggest which condition?
Compensation for hypoxia Explanation: A congenital heart defect with decreased pulmonary blood flow alters blood flow through the heart and lungs, resulting in hypoxia. To compensate, the body increases the oxygen-carrying capacity of RBCs by increasing RBC production, which causes the Hb level and Hct to rise. In anemia, the Hb level and Hct typically decrease. Altered electrolyte levels and other laboratory values are better indicators of dehydration. An elevated Hb level and HCT aren't associated with jaundice.
A client is newly diagnosed with pernicious anemia. The nurse emphasizes to the client the need to increase vitamin B12 intake by:
Taking vitamin B12 injections or nasal spray replacement. Explanation: The client with pernicious anemia will require lifelong supplementation of vitamin B12, available through injection or nasal spray administration. It must be given in these forms to ensure absorption. Oral vitamin B would not be absorbed because the client lacks the intrinsic factor in the stomach necessary for absorption. Chelation therapy is used to extract metals at toxic levels such as in lead poisoning.
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. Explanation: When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.
A young school-age child whose mother and aunt have bipolar disorder and whose father has depression is brought to the child psychiatrist's office by her father. He has custody of the child since the parents divorced. The father says that the child has problems with behavior, attention in school, and sleeping at night. The child says "My brain doesn't turn off at night." The psychiatrist diagnoses the child with attention deficit hyperactivity disorder (ADHD) with a possibility of bipolar disorder as well. What should the office nurse say to the father to reinforce what the psychiatrist said? Select all that apply.
• "The psychiatrist diagnosed your child with ADHD because of her attention and behavior problems at school." • "ADHD involves difficulty with attention, impulse control, and hyperactivity at school, home, or in both settings." • The psychiatrist is considering a bipolar diagnosis because of your child's family history of bipolar disorder and her sleep issues." Explanation: The client's school problems, the presence of first-degree relatives with bipolar disorder and depression, and her inability to sleep at night mirror aspects of both ADHD and bipolar disorder, which are difficult to distinguish from each other in children. Psychiatrists are reluctant to diagnose young children as bipolar. She may have only one disorder or both. Further monitoring and her response to medication will differentiate whether she is suffering from one of the disorders or both. Any comments indicating that the psychiatrist does not know what he or she is doing or that the child's perceptions of her illness are not valid will undermine any trust the father and child might be developing in their caregiver and so should be avoided.
Which of the following would be helpful in preventing suicide for clients about to be discharged from a psychiatric inpatient unit? Select all that apply.
• At discharge, give all clients with depression a card containing the crisis line phone number for their area. • Have all clients who have expressed suicidal ideation just prior to or during hospitalization make a written personal suicide prevention plan. • Educate family and friends of previously suicidal clients in ways to help clients remain safe after discharge. Explanation: Having resources such as a crisis line phone number and a specific prevention plan helps clients know what to do if they begin to feel they want to harm themselves. Likewise, having supportive people educated about how to help the client stay safe also improves the client's safety. Not all medications are lethal enough that access to 1 month's supply of medication should be limited. Further, such a limitation is likely to increase costs for clients, which may increase stress. It is unrealistic and potentially distressing to the client and family/friends to have the client under constant surveillance.
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
• Determine that there will be a latex-safe environment for surgery. • Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). • Notify the health care providers at the surgery center. Explanation: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current. The surgery can be safely performed at a free-standing surgery center as long as latex precautions are observed.
Which of the following actions should the nurse take when performing external chest compressions on a neonate born at 28 weeks' gestation?
Alternate chest compressions with ventilation. Explanation: Chest compressions should be alternated with ventilation to ensure breathing and circulation. Two fingers or two thumbs encircling hands, not the palm of the hand, are used to compress a neonate's sternum. The chest is compressed 100 to 120 times per minute. The proper technique recommended by the Neonatal Resuscitation Program is to use enough pressure to depress the sternum to a depth of approximately one-third of the anterior-posterior diameter of the chest.
An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Anticipatory guidance for the parents and adolescent should focus on which of the following as most important?
Because the incidence of testicular cancer is increased in adulthood among children who have had undescended testes, it is extremely important to teach the adolescent how to perform the testicular self-examination monthly. The undescended testicle is removed to reduce the risk of cancer in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the other testicle remains. Although discussing the adolescent's future plans is important, it is not the priority at this time. Because the adolescent has been dealing with the situation for a long time, the need for a sports physical at this time should not be a cause of emotional distress requiring a lot of psychological support.
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?
Clamp the catheter. Explanation: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.
Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine (Xylocaine) . To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's:
electrocardiogram (ECG). Explanation: Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Urine output is an indicator of pump effectiveness; CK and troponin levels monitor myocardial damage. Blood pressure and heart rate measurements are too nonspecific to help determine the effectiveness of parenteral lidocaine
A young client is being admitted to the psychiatric unit after her obsetrician's staff suspected she was experiencing a postpartum psychosis. Her husband said she was doing fine for 2 weeks after the birth of the baby, except for pain from the C-section and trouble sleeping. These symptoms subsided over the next 4 weeks. Then 3 days ago, the client started having anxiety, irritability, vomiting, diarrhea and delirium, resulting in her inability to care for the baby. Then the husband says, "I saw that my bottles of alprazolam and hydrocodone were empty even though I haven't been taking them." In what order of priority from first to last should the nurse do the following? a) Immediately place the client on withdrawal precautions. b) Assess the client for prior and current use of any other substances. c) Confirm with the client that she has in fact been using her husband's alprazolam and hydrocodone. d) Call the primary health care provider for prescriptions for appropriate treatments for opiate and benzodiazepine withdrawal.
C) Confirm with the client that she has in fact been using her husband's alprazolam and hydrocodone. b) Assess the client for prior and current use of any other substances. a) Immediately place the client on withdrawal precautions. d) Call the primary health care provider for prescriptions for appropriate treatments for opiate and benzodiazepine withdrawal.
What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day?
Complete regular admission procedures. Explanation: Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up, but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure.
A client is brought to the crisis intervention center by his wife, who states that he has recently become increasingly listless and less involved with his family. She reports that he sleeps poorly, eats little, and can barely perform basic self-care. She also reveals that 3 months ago he was in a car accident in which his best friend was killed. After the physician diagnoses acute depression, the nurse should anticipate administering:
Paroxetine, amitriptyline, doxepin, and imipramine are all antidepressants that may be ordered for this client. However, paroxetine, 20 mg P.O. every morning, is the only correct dosage. Amitriptyline is usually started at 75 to 150 mg P.O. daily in divided doses. Doxepin is started at 25 to 50 mg daily and may be titrated upward to a maximum daily dose of 300 mg. Imipramine is started at 50 to 75 mg daily and, if tolerated, titrated upward to a maximum daily dose of 300 mg.
When completing the Preoperative Checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
Inform the nurse anesthetist. Explanation: The nurse anesthetist administers the anesthetic agent and monitors the client's physical status throughout the surgery; the nurse anesthetist must have knowledge of all known allergies for client safety. The completed chart (with the Preoperative Checklist) accompanies the client to the operating room; any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the chart. The pre-anesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.
A 24-year-old primipara who has given birth to a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. Which information regarding normal weight gain should the nurse include in the teaching plan?
Gaining 30 g/day is a normal weight gain pattern. Explanation: Gaining 30 g or 1 oz a day is a normal weight gain pattern for a neonate. Initial weight loss that exceeds 10% of a neonate's birth weight is abnormal. Adding rice cereal to a bottle without a medical indication increases the risk of aspiration and may promote obesity. Doubling of the birth weight typically occurs around 5 months.
During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:
histrionic personality disorder. Explanation: This client's behaviors are typical of histrionic personality disorder, which is marked by emotional lability and attention seeking. The client constantly seeks and demands attention, approval, or praise; may be seductive in behavior, appearance, or conversation; and is uncomfortable except when she is the center of attention. Clients with paranoid personality disorder are typically suspicious, cold, hostile, and argumentative. Avoidant personality disorder is characterized by anxiety, fear, and social isolation. Borderline personality disorder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships.
