NCLEX-RN review questions

Ref # 4592 The nurse has received a physician's order that reads: Administer fentanyl 50 mcg IV every 1 to 2 hours, as needed, for pain. Fentanyl is packaged as 100 mcg/2 mL ampules. How many milliliters of fentanyl will the nurse draw up to administer to the client? mL.

1ml

A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at this age? a. Fear of pain b. Separation anxiety c. Loss of control d. Bodily injury

b. Separation anxiety While a toddler will experience all of the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years.

Ref # 4356 The nurse is caring for a client with chronic renal failure. Which of the following orders written by the health care provider would the nurse question? Sodium polystyrene sulfonate (Kayexalate) 50 grams rectally today Potassium chloride (Micro-K) 20 mEq daily with breakfast Recombinant human erythropoietin (Epoetin alpha) 100 units/kg SubQ 1-3 times/week Furosemide (Lasix) 40 mg orally twice a day

Potassium chloride (Micro-K) 20 mEq daily with breakfast

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement? "I will talk with him and try to figure out what to do or what the problem is." "Ignore him and get the rest of your work done. Someone else can care for him the rest of the day." "He may be scared and taking it out on you. Let's talk to figure out what to do next." "He has a lot of problems. You need to have patience with him."

"He may be scared and taking it out on you. Let's talk to figure out what to do next."

Ref # 2235 The nurse manager is interviewing a prospective employee who just completed the agency application. Which approach should the nurse manager use to assess skills competencies of this potential employee? "Let's talk about your comfort zone for working independently." "Let's review your skills checklist for type and level of skill for tasks." "What degree of supervision for basic care do you think you need?" "What types of complex client-care tasks or assignments do you prefer?

"Let's review your skills checklist for type and level of skill for tasks."

The nurse is caring for a client with chronic renal failure who is undergoing peritoneal dialysis. The nurse notes that the dialysate solution is instilling very slowly. Which of the following actions would be appropriate for the nurse to implement? (Select all that apply.) Reposition the client Assess for headache and hypertension Assess for bruit or vibration Check tubing and catheter for kinks

"My child doesn't like many fruits and vegetables, but really loves milk." Slow dialysate instillation may be due to a partially obstructed tube or catheter. Checking for kinks and repositioning may facilitate improved instillation of this fluid. Assessment for bruit or headache and hypertension are appropriate for hemodialysis situations, not peritoneal dialysis.

Ref # 5027 A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.) "My wishes for end of life treatment are stated in writing." "I should sit down and discuss my wishes for end of life care with my loved ones." "A living will must be renewed by a designated family member each time I am hospitalized." "It lists all my assets and how they should be divided among my family after I die." "A living will is a legal document that becomes a permanent part of my health care record." "I will need to identify someone to be my health care proxy."

"My wishes for end of life treatment are stated in writing." "I should sit down and discuss my wishes for end of life care with my loved ones." "A living will is a legal document that becomes a permanent part of my health care record." "I will need to identify someone to be my health care proxy."

The nurse is caring for a client with urinary incontinence. The client asks the nurse about the use of biofeedback to treat this condition. What is the most appropriate response by the nurse? "Medications are the approved method of treating this type of problem." "This type of treatment has been used successfully to manage urinary incontinence." "Biofeedback has not been shown to be very helpful for urinary incontinence problems." "Surgery is generally needed in order to produce any real improvement."

"This type of treatment has been used successfully to manage urinary incontinence." Biofeedback is a widely used and effective method to manage urinary incontinence, with rehabilitation of the pelvic floor muscles the treatment goal. The other statements are potential treatment options but are untrue statements. Depending on the cause of the incontinence, medications such as estrogens, alpha-adrenergic drugs, and the antimuscarinic drug tolterodine (Detrol) may be prescribed and/or surgery may be indicated.

Ref # 2367 A client calls the evening health clinic to state, "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse's initial response to the client? "Have you eaten anything today?" "What else do you know about this type of insulin?" "Are you taking any other insulin or medication?" "What are you feeling at this moment?"

"What are you feeling at this moment?"

An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be administered intravenously over 40 minutes. In mL/hour, what will be the setting for the IV delivery system? _______mL/hr.

300mL/hr Using ratio proportion: First, convert 22 pounds to kilograms (22/2.2) = 10 kg 20 mL/kg = 20 x 10 kg = 200 mL 200 mL/40 minutes = x mL/60 minutes (in an hour) 200 x 60 = 12000/40 = 300 mL/hr Using dimensional analysis: 20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300 mL/hr

Ref # 1248 The nurse is providing discharge teaching to a client with asthma. The nurse should warn against the concurrent use of which over-the-counter medications? Cortisone ointments for skin rashes Aspirin products for pain relief Histamine blockers for gastric distress Cough medications containing guaifenesin

?

The nurse has just listened to the change of shift report on an orthopedic unit. Which of the following clients should the nurse check first? A 72 year-old who returned from a right hip replacement surgery two hours ago A 20 year-old in skeletal traction for two weeks since a motorcycle accident A 75 year-old who is in skin traction of the left leg prior to a scheduled fractured hip repair surgery A 16 year-old who had an open reduction of a fractured wrist 10 hours ago

A 72 year-old who returned from a right hip replacement surgery two hours ago

Ref # 2274 A client has started clozapine therapy. What information should the nurse emphasize to the client about this medication during discharge teaching? The tablet should be swallowed with at least 8 ounces of water It may cause hypoglycemia The client may experience dry skin A common side effect is extreme salivation

A common side effect is extreme salivation

A client who is unconscious is brought to the emergency department by an ambulance. What document should be given priority to guide the approach for the care of this client? A notarized original of the advance directive brought in by the partner The national statement of client rights and the client self-determination act Orders written by the health care provider in the emergency department The clinical pathway protocol of the agency and the emergency department

A notarized original of the advance directive brought in by the partner

Ref # 2373 An antibiotic is ordered to be administered to a 2 year-old child intramuscularly. The total volume of the injection equals 2 mL. What is the correct nursing action? Check with pharmacy for a liquid form of the medication Call to get a smaller volume ordered Administer the medication in two separate injections Give the medication in the dorsogluteal site

Administer the medication in two separate injections Intramuscular injections should not exceed a volume of 1 mL for infants and toddlers. Medication doses exceeding this volume should be split into two separate injections of 1 mL each. The nurse would insert the needle at a 90 degree angle into the anterolateral thigh muscle.

A nurse is assessing a newborn infant and observes low-set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. What priority focus in the maternal history should the nurse ask about? Family genetic disorders Alcohol use during pregnancy Use of vitamins and supplements during pregnancy Maternal and paternal ages

Alcohol use during pregnancy

The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a priority? Altered parenting Social isolation Ineffective coping Sexual dysfunction

Altered parenting The mother who abuses cocaine puts her newborn and any other children at risk for neglect and abuse. The continued use of drugs has the potential to impact parenting behaviors. Social service referrals are indicated for evaluation and follow-up.

A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" Which action should the nurse take next? Ask the client to talk about concerns regarding "hot" treatments Report the situation to the health care provider Document the situation and client response in the notes Talk with the client's family about the situation

Ask the client to talk about concerns regarding "hot" treatments In Hispanic folk medicine, it is believed that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states include pregnancy, hypertension, diabetes and indigestion. "Cold" diseases include pneumonia. These designations are symbolic and do not necessarily indicate temperature or spiciness. Care and treatment regimens can often be negotiated with clients within this framework. Also note that the correct response is the best answer because it is client-centered.

An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs), and is unable to drive. List the order of the steps in the case management process by dragging and dropping the options below. Identification of nursing diagnoses Assessment of biophysical and sociocultural considerations Referral to personal care attendant and transportation services Evaluation of progress towards client's goals Reassessment of health status and ADL ability

Assessment of biophysical and sociocultural considerations Identification of nursing diagnoses Referral to personal care attendant and transportation services Reassessment of health status and ADL ability Evaluation of progress towards client's goals

Ref # 1345 The nurse is administering the initial total parenteral nutrition (TPN) solution to a client. Which finding requires the nurse's immediate attention? Blood glucose of 350 mg/dL (19.4 mmol/L) Poor skin turgor Urine output of 300 mL in four hours Temperature of 99.5 F (37.5 C)

Blood glucose of 350 mg/dL (19.4 mmol/L)

Ref # 4437 There is an order to administer a vesicant chemotherapy medication intravenously (IV). Which nursing action is the priority before starting the flow of the medication? Ensure that two nurses check the accuracy of the medication and dose Use meticulous sterile technique with the intravenous line Check for blood return in the intravenous line Apply warm compresses to the skin surrounding the insertion site

Check for blood return in the intravenous line

Ref # 4560 The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take? Collaborate with the health care provider about the change of condition Make a clinic appointment with the primary health provider for follow-up care the next day Collaborate with the dietitian for increasing protein and calcium in the diet Teach a family member clean dressing change technique and address safety measures in the home

Collaborate with the health care provider about the change of condition

The charge nurse sends a certified nursing assistant (CNA) to help a registered nurse (RN) with the admission of a client with multiple health problems. Which of the following tasks would be appropriate for the the CNA to perform with the nurse during the admission process? (Select all that apply.) Collect a urine specimen Orient the client to the room Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown Observe and document the client's ability to walk to the bathroom

Collect a urine specimen Orient the client to the room Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown

Ref # 1277 The nurse is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law? Clinical specialty certification by an accredited organization Above-average performance reviews prepared by nurse manager Sworn statement that health care provider orders were followed Complete and accurate documentation of assessments and interventions

Complete and accurate documentation of assessments and interventions

Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy? Conserves time spent on planning Considers client and staff needs Frees the nurse manager to handle other priorities Allows requests for special privileges

Considers client and staff needs Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level.

Ref # 1871 A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager? Confront the nurse about the suspicions in a private meeting Consult with human resources personnel about the issue and needed actions Schedule a staff conference, without the nurse present, to collect information Counsel the employee to resign to avoid investigation and rumors

Consult with human resources personnel about the issue and needed actions

Ref # 2221 A client frequently admitted to the locked psychiatric unit repeatedly compliments and then invites one of the nurses to go out on a date. The nurse should take which of these approaches? Inform the client that the hospital policy prohibits staff to date clients Tell the client that such behavior is inappropriate and unethical Ask to not be assigned to this client or request to work on another unit Discuss the boundaries of a therapeutic relationship with the client

Discuss the boundaries of a therapeutic relationship with the client

A nurse is caring for a client with acute renal failure who has a subclavian vascular access port for hemodialysis. Which of these findings necessitates immediate action by the nurse? Elevated temperature Dry, hacking cough Chronic fatigue Pruritic rash

Elevated temperature An elevated temperature in this client would indicate a possible central line infection. This finding should be reported to the provider who should order wound and blood cultures. If a line infection is suspected, the line will need to be removed, necessitating alternate line placement for hemodialysis. Interventions to prevention line infection through maintenance of line sterility and stabilization of the site are a priority in any client with a central line. The other findings should be reported to the health care provider but a febrile reaction is the priority.

The nurse is caring for a 14 year-old child in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan? Assist to stand up at bedside within the first few hours Initiate the antibiotic therapy prescribed for 10 days Evaluate the movement and sensation of extremities Teach client isometric exercises for the legs

Evaluate the movement and sensation of extremities Following corrective surgery for scoliosis, the neurological status of the extremities requires priority attention in the PACU, as well as on the postop surgical unit. The other options may be done after the neurological status

Ref # 2497 The nurse administers an intermittent intravenous medication through a client's peripherally inserted central catheter (PICC) and disconnects the infusion from the PICC site. To best maintain patency of the PICC site, which action does the nurse take next? Apply a smooth, even flow when flushing the catheter Flush the catheter using a 3 - 5 mL sterile syringe Flush the catheter using a rapid push-pause technique Apply a negative pressure technique while flushing the catheter

Flush the catheter using a rapid push-pause technique

A client is NPO and receiving total parenteral nutrition (TPN). The nurse recognizes which of the following laboratory values is important to monitor regularly while the client is receiving the TPN? Cholesterol level White blood cell count Glucose Hemoglobin

Glucose The nurse recognizes that the glucose level should be monitored regularly while the client is on TPN because it is common to develop hyperglycemia. The white blood count, cholesterol and hemoglobin don't directly relate to the TPN infusion.

A mother, who has been exclusively breastfeeding her 6 month-old, requests more information about meeting the nutritional needs of her infant. What information will the nurse provide? Begin a regular schedule of meals and snacks, offering a variety of foods Offer finger foods to encourage self-feeding during family meals Cut back on the number of times a day the infant receives breastmilk Gradually begin adding pureed iron-rich meat and/or cereal as the first foods

Gradually begin adding pureed iron-rich meat and/or cereal as the first foods The nurse should recommend increasing the number of times a day that complementary foods are offered while continuing to breastfeed. Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal should be the first complementary foods. After pureed foods, the next transition should be to add strained or mashed foods and then finger foods. From about one year of age, young children begin to have a regular schedule of meals and snacks.

The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should follow which of the following guidelines? Sodium-restricted High-fat, high-calorie foods Skim milk and low-fat dairy products Restricted calorie

High-fat, high-calorie foods The child with cystic fibrosis requires a well-balanced diet that is high in calories (approximately 2,900 to 4,500 calories a day). The diet should include increased amounts of protein, iron, salt, zinc and calcium (especially full-fat dairy products.) Fat does not need to be restricted because these children lose fat in the stool. Recall one of the characteristics of this disease is fatty, foul smelling stool.

A nurse is caring for a client who was successfully resuscitated from a pulseless arrhythmia. Which assessment is critical for the nurse to include in the plan of care? White blood count trends Hourly urine output Blood glucose every four hours Temperature every two hours

Hourly urine output Clients who have decreased glomerular perfusion from shock or other low blood pressure conditions are at risk for prerenal failure. Close observation of hourly urinary output is necessary for early detection of this condition in a client who has experienced a pulseless arrhythmia.

A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain associated with an MI is related to which of the following findings? Insufficient oxygenation of the cardiac muscle Fluid volume excess Arrhythmia An electrolyte imbalance

Insufficient oxygenation of the cardiac muscle Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with the normal cardiac circulation.

The nurse is providing discharge teaching for a client with a long leg cast. During instructions, the nurse should recommend which of these exercises for the affected extremity? Aerobic Range of motion Isometric Isotonic

Isometric A nurse should instruct the client on isometric exercises for the muscles of the casted extremity. This means the client should be instructed to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals of at least every four hours.

Ref # 4619 The health care provider has ordered the anti-infective tetracycline for a young woman. When teaching the client about the medication, what information would be necessary for the nurse to reinforce? It should be taken with food or milk It may cause staining of the teeth It may cause hearing loss It may decrease the effectiveness of some oral contraceptives

It may decrease the effectiveness of some oral contraceptives

In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize which approach? Eat smaller meals Limiting alcohol use Avoiding passive smoke Learning relaxation techniques

Learning relaxation techniques The only factor that can enhance the client's response to pain medication for angina is reduction of anxiety through relaxation methods. Anxiety may increase intensity to a point where pain medication outcomes are totally ineffective.

Ref # 2414 A client is recovering from hip replacement and is taking acetaminophen with codeine (Tylenol No. 3) every three hours for pain. Which finding associated with opioid analgesics does the nurse anticipate when assessing the client? Itching and bruising at the incision site Dry, unproductive cough Elevated serum glucose No bowel movement for three days

No bowel movement for three days Side effects of opioid analgesic use include respiratory depression, sedation and constipation. The incision site may be bruised after surgery and it may itch, pull or feel numb, but this is unrelated to oral opioid use. Dry mouth is a possible side effect of acetaminophen with codeine, but not necessarily dry cough.

The nurse is teaching a client about precautions while taking warfarin. The client should be instructed to avoid which type of over-the-counter medication? Laxatives containing magnesium salts Non-steroidal anti-inflammatory drugs (NSAIDs) Histamine blockers Cough medicines with guaifenesin

Non-steroidal anti-inflammatory drugs (NSAIDs) Clients should be warned not to take aspirin and other NSAIDs while taking warfarin. The combination may increase the response to warfarin and increase the risk of bleeding. If the health care provider prescribes the two medications together, the client will need to have bleeding times checked more frequently.

The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrates the shared governance model? Nursing departments share responsibility for client outcomes Non-nurse managers supervise nursing staff in groups of units Staff groups are appointed to discuss nursing practice and client education issues An appointed board oversees any administrative decisions

Nursing departments share responsibility for client outcomes

A nurse is performing physical assessments on adolescents. What finding should the nurse anticipate concerning female growth spurts? Occur about two years earlier than for males Start just prior to the onset of puberty Characterized by an increase in height of 4 inches each year Begin about the same time for males

Occur about two years earlier than for males Normally, females in their teenage years experience a growth spurt about two years earlier than their male peers.

A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? Allergies Scabies Pinworm Ringworm

Pinworm

A 10 year-old child is recovering from a splenectomy after a traumatic injury. The child's laboratory results show a hemoglobin of 8.8 g/dL and a hematocrit of 26%. What is a priority approach that the nurse should include in the plan of care? Promote a diet rich in iron and lean red meats Restrict the consumption of carbonated beverages Plan for regularly scheduled rest periods Encourage bed activities and games for the next five days

Plan for regularly scheduled rest periods The initial priority for this client is rest due to the lack of sufficient red blood cells to carry oxygen. The normal hemoglobin is between 10.0 and 15.0 g/dL, and the normal hematocrit is 35% to 45% for a child this age. Note that all of the options are correct actions that may be used for various reasons.

The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? Provide stoma care for a client with a well-functioning ostomy Care for a recent complicated double barrel colostomy Teach the initial ostomy care to a client and family members Assess the function of a newly created ileostomy

Provide stoma care for a client with a well-functioning ostomy The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN.

Ref # 4613 The nurse is reviewing the medication administration record for a newly admitted client. The client is prescribed the beta blocker propranolol, but is not diagnosed with hypertension and does not have a history of heart disease. Which health issue might best explain the reason for prescribing propranolol? Raynaud's disease Parkinson's disease Schizophrenia Essential tremors

Raynaud's disease

Ref # 4517 The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? Increase client understanding of discharge instructions Reduce insurance costs Increase satisfaction with nursing care Reduce readmissions to the hospital

Reduce readmissions to the hospital

Ref # 2328 A client with goiter is treated preoperatively with potassium iodide. What should the nurse recognize as the purpose of this medication? Reduce vascularity of the thyroid gland Balance serum enzymes and electrolytes Correct chronic hyperthyroidism Destroy the thyroid gland function

Reduce vascularity of the thyroid gland

A 2 year-old child is brought to the emergency department at 2:00 pm. The mother states: "My child has not had a wet diaper all day." The child is pale, with a heart rate of 132 beats per minute. What other assessment data would the nurse obtain next to help determine an admitting diagnosis? Status of the eyes and the tongue Description of play activity Dietary patterns in the past 48 hours History of fluid intake

Status of the eyes and the tongue

Ref # 1298 A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first? Spontaneous pneumothorax with a respiratory rate of 38 Viral pneumonia with atelectasis Tension pneumothorax with slight tracheal deviation to the right Acute asthma with episodes of bronchospasm

Tension pneumothorax with slight tracheal deviation to the right

The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.) The UAP applies moisture barrier cream to the client's excoriated perianal area The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor

The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall

The nurse works in an ambulatory care clinic where there are four children with gastrointestinal findings waiting to be seen by the health care provider. Which child is at greatest risk for developing metabolic acidosis? The child who has been vomiting for more than 48 hours The child with alternating constipation and diarrhea The child with nausea and anorexia The child with severe diarrhea for 24 hours

The child with severe diarrhea for 24 hours Severe diarrhea can lead to excessive loss of sodium bicarbonate from the body. If untreated, severe diarrhea can lead to metabolic acidosis. Prolonged vomiting, on the other hand, can result in metabolic alkalosis (due to acid loss.) Severe anorexia can also result in metabolic alkalosis.

A nurse is assigned to care for four clients. After listening to change-of-shift report, how would the nurse prioritize care for the following clients? (Drag the responses into the correct order.) The client with a tracheostomy The client who is in skeletal traction The client scheduled for a colonoscopy The postoperative client who has an order to be discharged to home

The client with a tracheostomy The client scheduled for a colonoscopy The client who is in skeletal traction The postoperative client who has an order to be discharged to home

Ref # 4599 The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? The nurse could be fired for breach of confidentiality There won't be any consequences because the client's real name was not used The nurse could be reprimanded for not clearing the information first with hospital administration There won't be any consequences because the information was posted on a website for nursing professionals

The nurse could be fired for breach of confidentiality

A client exhibiting confusion has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive person (UAP)? Assist the client with activities of daily living Document mental status and muscle strength Monitor the client's physical safety Document client's status every two hours

The person to whom the activity is delegated must be capable of performing it. The UAP is capable of assisting clients with basic needs and routine tasks. Only the nurse can monitor and evaluate the client's condition.

A 3 year-old child is brought to the pediatric clinic after experiencing the sudden onset of irritability, thick muffled voice, croaking on inspiration and skin that's hot to the touch. The child sits leaning forward, tongue protruding, drooling and has suprasternal retractions What should the nurse do first? Notify the health care provider of the child's status Collect a sputum specimen Examine the child's throat Prepare the child for x-ray of upper airways

These findings suggest epiglottitis, which is a medical emergency. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate medical attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

The nurse assesses a client who has been taking haloperidol for several months. Which adverse effect must be immediately reported to the health care provider? Constipation Dry, harsh cough Tongue thrusting and facial grimacing Muscle flaccidity

Tongue thrusting and facial grimacing Dystonias often involve tongue protrusions and muscle rigidity. Dystonias usually resolve after the medication is discontinued, but the client may require antihistamine and antiparkinsonian therapy. Dystonic movements have the potential of becoming irreversible and must be immediately reported to the health care provider. Some of the more common side effects of haloperidol include nausea, vomiting, diarrhea, dry mouth, nervousness, drowsiness, insomnia, and blurred vision.

A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? a. "I see this is frustrating for you. I have a few minutes so let's talk." b. "I am surprised that you are upset. The request could have waited a few more minutes." c. "Let's talk. Why are you upset about this?" d. "I apologize for the delay. I was involved in an emergency."

a. "I see this is frustrating for you. I have a few minutes so let's talk." This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs.

The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group) manual for which purpose? a. Determine reimbursement for a medical diagnosis b. Identify findings related to a medical diagnosis c. Classify nursing diagnoses from the client's health history d. Implement nursing care based on case management protocol

a. Determine reimbursement for a medical diagnosis DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment.

The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? a. Able to tolerate a regular diet b. Post-operative pain is managed c. Psychological counseling is scheduled d. Able to ambulate in the hallway with assistance

b. Post-operative pain is managed An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority.

The nurse is providing preprocedural education to the client preparing for a barium enema. What statement made by the client indicates a need for further education? a. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure." b. "I will use the prescribed laxative before the procedure." c. "I will not eat or drink anything after midnight before the procedure." d. "A barium enema is used to examine the upper and lower GI tracts."

d. "A barium enema is used to examine the upper and lower GI tracts." A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid while x-ray images are taken. After the procedure, a small amount of barium will be immediately expelled and the remainder will be excreted in the stool. Because barium liquid may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help expel the barium from the body.

The nurse is caring for a 50 year-old client diagnosed with advanced cirrhosis of the liver. Which nursing diagnosis should take priority? a. Fluid volume excess: ascites b. Risk for injury related to peripheral neuropathy c. Altered nutrition: less than body requirements d. Risk for injury: hemorrhage

d. Risk for injury: hemorrhage Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. In addition, hemorrhage, especially from esophageal varices, can be life-threatening. This takes priority over the other nursing diagnosis.

A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take Alka-Seltzer for an upset stomach?" What is the best response by the nurse? "Use about half the recommended dose of Alka-Seltzer." "Select another antacid that does not inactivate warfarin (Coumadin)." "Avoid Alka-Seltzer because it contains aspirin." "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)."

"Avoid Alka-Seltzer because it contains aspirin." Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin is an antiplatelet drug and taking this with warfarin will potentiate the anticoagulant effects of warfarin (Coumadin), which may increase the risk of bleeding.

At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being evaluated for cerebral palsy (CP). Which information provided by the parents would support this diagnosis? "Our child isn't talking yet." "We think our child seems smaller than other babies this age." "Mealtime is so messy when he tries to feed himself." "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg."

"He crawls by pushing off with one hand and leg while dragging the opposite hand and leg." Cerebral palsy refers to a group of conditions that affect movement, balance and posture. Prematurity, infections during pregnancy, and asphyxia during labor and delivery are risk factors for CP. Some children with CP may have delays in learning to roll over, sit, crawl or walk. Because this child was born prematurely, it would be expected that he would be smaller than other babies. At this age, most children can say a few words (like "mama"), but they are not talking, and mealtime can get pretty messy.

After four electroconvulsive treatments over two weeks, a client is very upset and states, "I am so confused. I lose my money. I just can't remember telephone numbers." The most therapeutic response for the nurse to make is which of these statements? "Don't get upset. The confusion will clear up in a day or two." "You were seriously ill and needed the treatments." "I can hear your concern and that your confusion is upsetting to you." "It is to be expected since most clients have the same results."

"I can hear your concern and that your confusion is upsetting to you." Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed with a movement to the problem-solving stage.

The nurse is working in a community health clinic answering telephone calls. Which client would the nurse recommend to be seen immediately by a health care provider? "I was started on some medicine yesterday for a urine infection and now my lower belly hurts when I go to the bathroom." "I am an diabetic and today I have been going to the bathroom every hour." "I started my period and now my urine has turned bright red." "I went to the bathroom and my urine looked very red but it didn't hurt when I went."

"I went to the bathroom and my urine looked very red but it didn't hurt when I went." The client with painless gross hematuria needs to be seen right away because this finding is closely associated with bladder cancer or kidney problems. The other complaints can be handled over the phone.

A nurse is discussing Kawasaki disease with a group of student nurses. What statement made by a student about Kawasaki disease is incorrect and needs to be clarified? "Kawasaki disease occurs most often in boys, who are younger than 5 years-old and of Hispanic descent." "It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes." "Initial findings include a sudden high fever, often up to 104 F (40 C), which lasts one to two weeks." "In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain."

"Kawasaki disease occurs most often in boys, who are younger than 5 years-old and of Hispanic descent." Kawasaki disease occurs most often in boys who are younger than 5 years-old and of Asian descent (especially Japanese). Findings in the initial phase include extremely red eyes (conjunctivitis); a rash on the main part of the body (trunk) and in the genital area; red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands and the soles of the feet; swollen lymph nodes in the neck. Fever reduction signals the second phase, when the findings slowly go away. In the third phase, except for abnormal lab values, findings are gone (unless cardiac complications develop). The disease lasts from 2 to 12 weeks without treatment. With treatment, the child usually improves within 24 hours.

A client is admitted to a voluntary hospital mental health unit with the diagnosis of suicidal ideation. The client has been on the unit for two days and now states, "I demand to be released now!" The appropriate response from the nurse should be which of these statements? "You have a right to sign out as soon as we get the health care provider's discharge order." "You cannot be released because you are still at risk of being suicidal." "Let's discuss your decision to leave and then we can prepare you for discharge." "You can be released only if you sign a no suicide contract before you leave."

"Let's discuss your decision to leave and then we can prepare you for discharge Clients who are voluntarily admitted to the hospital have a right to demand and obtain release. By discussing the decision to leave the nurse has an opportunity to suggest or implement interventions other than discharge. The client may just need to talk through thoughts or feelings.

A client who is newly diagnosed with hypertension is prescribed benazepril. What is the most important point to make when teaching the client about this medication? "Notify the health care provider if there is a change in your voice." "Monitor your blood pressure and pulse regularly." "Take medication as directed at the same time each day, even if you feel well." "Call your health care provider if you develop a dry cough."

"Notify the health care provider if there is a change in your voice." Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of the side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to require discontinuation of the drug. But the most important point to make is that if the client's voice changes or "sounds funny" or there is any swelling of the lips, tongue or throat, the client should contact the health care provider because this could indicate angioedema, a potentially fatal condition.

A client comes into the community health center upset and crying, stating: "I will die of cancer now that I have this disease." The client hands the nurse a piece of paper with the word "pheochromocytoma" written on it. What would be the best initial response by the nurse? "This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline." "Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor." "You probably have had episodes of sweating, heart pounding and headaches. Is that correct?" "Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications."

"Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications." All of the options are correct information. The best response of the nurse is to address the issue presented by the client, which is "fear of cancer." Pheochromocytomas may release large amounts of adrenaline into the bloodstream after an injury or during surgery. For this reason, they can be life-threatening if unrecognized or untreated.

The nurse is reviewing medications with a client diagnosed with heart failure. The client asks the nurse how much longer he has to take the prescribed diuretic. Which is the best response by the nurse? "Please talk to your health care provider about medications and treatments." "You will have to take this medication for about a year." "The medication must be continued as long as the fluid problem needs to be controlled." "As you urinate more, you will need less medication to control fluid."

"The medication must be continued as long as the fluid problem needs to be controlled." The most therapeutic response is the one that addresses the client's health condition and gives the client accurate information, which is that he will take the medication for as long as needed to treat his medical condition. The nurse should determine if the client understands why he is taking this and any other medications and to reinforce teaching on possible side effects or adverse effects and when to notify the health care provider.

A client states, "I feel funny." The nurse uses electronic equipment to obtain vital signs and notes these findings: blood pressure 100/56 mm Hg, pulse 38, respirations 26. The client's previous reading: blood pressure 130/88 mm Hg, pulse 82, respirations 21. List the correct order of actions the nurse should now take (with 1 being the top priority). 1. Anticipate the need for ECG, oxygen administration, and emergency pacing 2. Assess for chest pain, dyspnea, low oxygen saturation, restlessness or other signs of respiratory or cardiac impairment 3. Notify the health care provider 4. Simultaneously check an apical and radial pulse manually

4, 2, 3, 1 The sudden drop in both blood pressure and pulse indicate an acute cardiovascular event requiring rapid assessment and intervention to prevent cardiac arrest. At this point, the patient is not in crisis but needs a quick targeted assessment. Verify the bradycardia manually; perfusion may not occur with some arrhythmias, such as premature ventricular contractions, so checking the apical rate while palpating a distal pulse provides a quick assessment. Assessment for cardiovascular and respiratory instability is next. With all the assessment data in hand, it's time to contact the health care provider, anticipating the need for ECG, oxygen as well as interventions to improve cardiac output such as atropine IV and cardiac pacing.

The nurse working in the intensive care unit (ICU) is told that a client is being newly admitted with a diagnosis of hyperglycemic hyperosmolar nonketotic state (HHNS). The nurse would expect which of the following clinical findings in this client? (Select all that apply.) 1. History of type 1 diabetes mellitus 2. Ketonuria 3. Metabolic acidosis 4. Severe dehydration 5. Blood glucose level of at least 600 mg/dL (33.33 mmol/L)

4. Severe dehydration 5. Blood glucose level of at least 600 mg/dL (33.33 mmol/L) The typical client with HHNS will have a plasma glucose level of 600 mg/dL (33.33 mmol/L) or greater, high serum osmolality, profound dehydration, a serum pH greater than 7.3 and some alteration in consciousness. Unlike diabetic ketoacidosis, however, there is little to no ketosis. HHNS usually presents in older clients with type 2 diabetes mellitus who have some concomitant illness (usually an infection) that leads to reduced fluid intake, or who do not adhere to their diabetic medications and diet. All clients with HHNS require hospitalization and rapid treatment to correct the profound hypovolemia and hyperglycemia characteristic of this condition.

The client is newly diagnosed with gastroesophageal reflux disease (GERD). Which statement(s) made by the client indicates a need for further education about this disease? (Select all that apply.) "A bedtime snack may help me sleep better." "When I have a headache I'll be sure to take aspirin instead of acetaminophen." "I'll wait a while after eating before I go exercise at the gym." "I will take my omeprazole (Prilosec) as needed when I have heartburn." "I will drink less coffee and cola." "I am going to enroll in a smoking cessation class."

A bedtime snack may help me sleep better." "When I have a headache I'll be sure to take aspirin instead of acetaminophen." "I will take my omeprazole (Prilosec) as needed when I have heartburn." GERD occurs as a result of gastric secretions from the stomach moving up the esophagus, usually because the lower esophageal sphincter is too relaxed. The client should eat meals several hours before lying down and give up those late night snacks which may trigger bedtime symptoms. Food and beverages that may trigger symptoms, such as caffeine and carbonated beverages, should be avoided. Proton pump inhibitors such as omeprazole (Prilosec) may take one to four days for their full effect, so they should be taken routinely, and a fast-acting antacid should be used for acute relief of heartburn symptoms. Aspirin and NSAIDs can aggravate GERD, so they should be avoided, and alternatives such as acetaminophen should be used instead. Avoiding tobacco and losing weight may also help improve heartburn.

It is the start of the shift and the nurse has just finished listening to a report on four clients. Which client should the nurse assess first? A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of 88/58 A client with a diagnosis of a concussion and who doesn't remember the motor vehicle accident A client diagnosed with viral meningitis and has signs of meningeal irritation A client diagnosed with generalized seizures who complains of a headache following an observed seizure

A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of 88/58 Hypotension adversely affects cerebral perfusion following a traumatic brain injury. Both hypotension and hypoxia are the greatest threats to functional outcomes in brain injury and must be corrected early, taking priority over other interventions for brain injury. Headache after a seizure is expected, amnesia is common with a concussion, and meningeal irritation is an expected finding with viral meningitis, making these clients a lower priority at this point.

A nurse from the mental health unit is reassigned to the pediatrics unit and will be caring for a child with asthma. Which of these findings would the charge nurse emphasize as the first thing to indicate a worsening condition in the child? Coughing, especially if the cough is frequent and occurs in spasms A downward trend in peak flow rates as measured by a peak flow meter Increased need to use bronchodilators An audible whistling or wheezing when the child exhales

A downward trend in peak flow rates as measured by a peak flow meter

The nurse is caring for a client who is experiencing frightening hallucinations that are markedly increased at night. The client's partner asks to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse? a."Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety." b."No, your presence may cause the client to become more anxious." c. "No, it would be best if you brought the client some reading material that the client could read at night." d. "Yes, would you like to spend the night when the client's behavior indicates that the client is or will be frightened?"

A."Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety." Encouragement of a family member or a close friend to stay with the client in a quiet surrounding cannot only help increase orientation, but can also minimize confusion and anxiety. The visitor could also report to the nurse any unusual findings of the client. This would be the most supportive approach for this client.

A parent of a 14 month-old is sharing concerns with the nurse. Which statement by a parent would alert a nurse to assess for iron-deficiency anemia in the toddler? "My child doesn't like many fruits and vegetables, but really loves milk." "I can't understand why my child is not eating as much as four months ago." "My child doesn't drink a whole glass of juice or water at one time." "I know there is a problem since my baby is always constipated."

About two to three cups of milk a day are sufficient for the young child's needs. Sometimes excess milk intake, a habit carried over from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called milk anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of excessive milk ingestion.

Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse? Give two rescue breaths Deliver five abdominal thrusts Maintain an open airway Check for a carotid pulse

According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations).

The nurse needs to make frequent detailed client assessments for pressure sore risk. Which client has the highest risk for developing a pressure sore? A 40 year-old wearing a controlled ankle motion walker following surgical repair of a ruptured tendon A 75 year-old diagnosed with peripheral vascular disease and needs assistance to walk A 68 year-old with left-sided paresthesia who is incontinent of urine A 55 year-old in balanced-skeletal traction for a fractured femur

According to the Braden Scale, the risk for developing pressure sores is rated on a scale of 1 to 4 for each of these factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear; a score of 12 or lower represents a high risk. With all other risk factors being equal, the 68 year-old client with paresthesia and who is incontinent of urine has the greatest risk for developing a pressure sore.

The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? a. Left foot is cool to the touch b. Absent left pedal pulse using Doppler analysis c. Inability to palpate the left pedal pulse d. Acute pain in the left lower leg

Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider.

The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin? A school-aged child who has swallowed a handful of iron-fortified vitamins A toddler who has eaten an undetermined number of ibuprofen tablets A preschooler who bit into a laundry detergent pod An infant who is diagnosed with botulism

An infant who is diagnosed with botulism Food-borne botulism can be treated by removing whatever contaminated food is in the stomach by using enemas (or by inducing vomiting) and administering a Botulinum antitoxin. Children with iron poisoning and who are breathing normally can be given a strong laxative fluid; severe poisonings require IV chelation therapy. For NSAID poisoning, sometimes activated charcoal is given (usually within 1 hour of ingestion); massive overdoses may require orogastric lavage because there is no specific antidote for ibuprofen. Since laundry detergent is an alkaline substance, the most commonly used therapy is dilution/irrigation/wash, especially for burns to the skin and eyes. Tracheal intubation with ventilation may be required if the child swallowed the laundry detergent.

A male client is preparing for discharge after an acute myocardial infarction. The client asks the nurse about sexual activity once the client is home. What should be the nurse's initial approach? Answer the questions accurately in a private environment Schedule a private, uninterrupted teaching session with both the client and the partner Assess the client's knowledge about the current health problems Give the client written material from the American Heart Association about sexual activity with heart disease

Assess the client's knowledge about the current health problems The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse should perform a focused assessment to gather additional data prior to planning and implementing nursing interventions.

A nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. Which intervention should the nurse take first? Assess the family's patterns for dealing with death Ask about their present religious affiliations Explain the stages of death and dying to the family Recommend an easy-to-read book on grief

Assess the family's patterns for dealing with death When a new problem is identified, it is important for the nurse to first collect accurate information. This is crucial to ensure that the client and the family's needs are adequately identified in order to plan and implement nursing care. Once the situation has been assessed and a plan has been established, the nurse can focus on teaching or referral to other resources.

A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority? Show the mother films on the physiology of lactation Give the mother several illustrated pamphlets Give the mother privacy for the initial feeding Assist the mother to position the newborn at the breast

Assist the mother to position the newborn at the breast All of the approaches should be helpful in teaching. However, the priority is to place the infant to the breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.

The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two days. Which statement by the nurse provides the best nutritional information for the child? Clear liquids and gelatin for 24 hours NPO for 24 hours, then rehydrate with milk and water Continue with the regular diet and include oral rehydration fluids Correct Response Offer bananas, apples, rice and toast as tolerated

Continue with the regular diet and include oral rehydration fluids Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and toast) diet may be appropriate.

A couple attempting to conceive asks the nurse when ovulation occurs. The woman reports a regular 32-day cycle. Which response by the nurse is correct? Days 11-13 Days 7-10 Days 14-16 Days 17-19

Days 17-19 Ovulation occurs 14 days prior to menses. Considering that the woman's cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day.

The health care provider orders potassium iodide (SSKI) drops for a client scheduled to undergo a thyroidectomy. How should the nurse administer the medication? Assist the client to gargle and then spit out the solution Administer it on an empty stomach Dilute the drops in 180 mL of water, milk or juice Place the drops directly on the client's tongue

Dilute the drops in 180 mL of water, milk or juice Potassium iodide drops should be mixed with water, fruit juice, milk, broth or even formula; the client can use a straw to drink the mixture. To minimize gastrointestinal irritation, it can be given after meals or with food. The medication is used preoperatively, 10 to 14 days before surgery, to reduce the size and vascularity of the thyroid gland.

Ref # 2035 The nurse is caring for a pregnant woman who is diagnosed with pregnancy induced hypertension (PIH) and is receiving magnesium sulfate intravenously. During assessment of the client, the nurse notes that respirations are 12, pulse and blood pressure have dropped significantly, and the eight-hour urine output is 200 mL. What should the nurse do first? Discontinue the magnesium sulfate Perform additional assessments Call the health care provider immediately Administer calcium gluconate

Discontinue the magnesium sulfate

The clinic nurse is caring for a 15 month-old child with a first episode of otitis media. Which intervention should the nurse include in the instructions to the child's parents? Explain that the child should complete the full five days of antibiotics Describe the tympanocentesis to detect persistent infections Emphasize the importance of a return visit after completion of antibiotics Provide them with handout describing care of myringotomy tubes

Emphasize the importance of a return visit after completion of antibiotics The usual treatment for otitis media is oral antibiotics for 10 to 14 days. The child should be examined again after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion.

A nurse is caring for a 2 year-old child who is being treated for lead poisoning by chelation therapy. The nurse should be alert for which side effect of chelation therapy? Hepatomegaly Ototoxicity Neurotoxicity Hypocalcemia

Hypocalcemia Injections of ethylenediaminetetraacetic acid (EDTA) or other chemicals bind, or chelate, to iron (and some other metals), which are then eliminated from the body. Since chelation therapy removes minerals from the body, there is a risk of developing low calcium levels (hypocalcemia) and bone damage.

The father of an 8 month-old asks the nurse if the child's vocalizations are normal for his this age. Which sound should the nurse expect from a child at this age? Laughter Throaty sounds Cooing Imitation of sounds

Imitation of sounds such as "da-da" is expected at this time. Laughter occurs after the initial cooing.

A 30 year-old primigravida arrives at the labor and delivery unit to be admitted for severe preeclampsia. She states she has a headache, and lab results indicate elevated liver enzymes. Place the cursor over the area of the client's body that would provide you with more information about her laboratory results.

Liver enzymes can become elevated when hepatic blood flow is obstructed by fibrin deposits due to hemolysis in severe preeclampsia. Subsequent liver distention follows and epigastric pain. The liver is located in the right upper quadrant of the abdomen.

An 8 year-old child is hospitalized with minimal-change disease (MCD). The nurse assists the child to select a lunch menu. Which menu selection is the best choice? Grilled chicken strips, corn on the cob with 1 pat of butter, skim milk Bologna and cheese sandwich with mustard, vanilla pudding snack, skim milk Peanut butter and sliced banana sandwich, apple, skim chocolate milk Frankfurter on bun (plain), strawberry gelatin dessert, skim chocolate milk

MCD is a kidney disease in which large amounts of protein are lost in the urine. Corticosteroids are used to treat the disease; ACE inhibitors and diuretics are used to treat the edema. Treatment also includes eating a healthy, low-sodium diet with high-quality protein. Of the given choices, grilled chicken strips, corn on the cob and a glass of skim milk has the smallest total sodium content (less than 500 mg) and is the healthiest diet. Since nearly every layer of a sandwich is loaded with salt, the bologna and cheese sandwich (with around 1260 mg sodium) and the frankfurter on the bun (717) are not the best choices. However, the peanut butter and sliced banana sandwich, apple and milk option is a close second (about 650 mg sodium.)

The nurse is providing care to a client who has just received an epidural for anesthesia during labor. The nurse recognizes which of the following as the most important nursing intervention following this procedure? Reduce the intravenous fluid infusion to a keep open rate Monitor maternal blood pressure for possible hypotension Monitor the fetus for possible tachycardia Monitor maternal pulse for possible bradycardia

Monitor maternal blood pressure for possible hypotension The most important nursing intervention for a woman who has received an epidural block is to frequently monitor the maternal blood pressure for signs of hypotension. After an epidural in the laboring client, IV fluids would be increased to prevent hypotension. The nurse would observe for signs of fetal bradycardia (not tachycardia) following an epidural and monitor for signs of maternal tachycardia, secondary to maternal hypotension.

A family arrives at the emergency department. A parent believes the child ingested an undetermined number of acetaminophen tablets approximately 1 hour ago. The serum acetaminophen level confirms acute poisoning. Which of these orders should be implemented first? Consultation with a medical toxicologist N-acetylcysteine (NAC) (Mucomyst) Oral activated charcoal therapy Ondansetron (Zofran) 0.1 mg/kg for nausea

N-acetylcysteine (NAC) (Mucomyst) The child should be started on the antidote for acetaminophen, N-acetylcysteine (NAC) because, without rapid intervention, acetaminophen toxicity can lead to liver failure and death. The amount ordered depends on the serum acetaminophen level. Although nausea and vomiting can be a side effect of acetaminophen poisoning (and even treatment with oral NAC), an antiemetic is not the priority. Activated charcoal is not recommended when more than 1 hour has elapsed after ingestion. Eventually, either a medical toxicologist or hepatologist can be consulted if the child experiences liver dysfunction.

A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect? Dysphagia Nystagmus Tardive dyskinesia Oculogyric crisis

Oculogyric crisis This refers to involuntary muscles spasm of the eye. There are medications to treat such side effects, for example trihexyphenidyl or benztropine.

The 72 year-old client, admitted for exacerbation of chronic obstructive pulmonary disease (COPD), is receiving 2 liters of oxygen per nasal cannula but is reporting dyspnea. An arterial blood gas (ABG) test is ordered and the results are: PaO2 40, pH 7.38, PaCO2 50, HCO3 28. Which option best explains the finding and indicates the required treatment? PaO2 is too low and oxygen flow rate should be increased PaO2 is too high and oxygen flow rate should be decreased PaO2 is within normal limits and the oxygen flow rate should not be changed PaCO2 is too high and deep breathing should be encouraged

PaO2 is too low and oxygen flow rate should be increased This client's ABGs show severe hypoxemia and compensated respiratory acidosis. The PaO2 level correlates to an oxygen saturation level of approximately 80%, and should be treated by titrating the oxygen flow rate upwards to maintain a saturation of 88-91% in a client with COPD. As the exacerbation is resolved and respiratory function improves, the oxygen flow rate should then be titrated down (to maintain the saturation levels above). The likelihood of decreasing the respiratory drive from oxygen administration with proper titration to saturation levels is low, compared with the potentially serious consequences of hypoxemia. The oxygen flow rate often needs to be adjusted upwards with activity in advanced COPD, to meet the demands of the activity. Appropriate administration of oxygen titrated to the specific client needs is an essential component of care. The compensated respiratory acidosis shown in these labs is mild and is not a priority for treatment at this time.

The RN is working in a clinic where a client presents with a painful, blistering rash on the hip. The health care provider diagnoses shingles (herpes zoster). What is the priority nursing diagnosis? Risk for impaired skin integrity related to skin lesions Knowledge deficit related to disease process Pain related to nerve root inflammation and skin lesions Risk for infection related to skin lesions

Pain related to nerve root inflammation and skin lesions Shingles is a reactivation of the herpes zoster virus responsible for chickenpox. It is characterized by a vesicular rash in a unilateral dermatomal distribution. The first symptom of shingles is usually pain, tingling, or burning before the blisters form. The pain and burning may be severe, and can lead to long-term residual pain, known as postherpetic neuralgia. Early appropriate treatment with an antiviral medication such as acyclovir can reduce these long-term complications, as well as the duration and severity of the initial symptoms. Pain is the priority nursing diagnosis. It is important that the client keeps the sores clean and avoids contact with people who haven't gotten the herpes zoster vaccine or who haven't had chickenpox, as well as people with weakened immune systems, until the rash crusts over and heals.

The nurse is caring for a 10 month-old infant diagnosed with iron-deficiency anemia. Based on this diagnosis, which of these findings should the nurse anticipate? Poor appetite Hemoglobin level of 12 g/dL A heart rate between 80 and 130 Pale mucosa of the eyelids and lips

Pale mucosa of the eyelids and lips In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild-to-severe tachycardia. The normal heart rate of infants typically ranges from 120 to 180 BPM. The normal hemoglobin range for children is about 11 to 13 gm/dL.

A nurse is caring for a 69 year-old client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? Palpate for a thrill over the fistula Feel for a bruit over the fistula Observe for edema proximal to the site Irrigate with 5 mL of 0.9% normal saline

Palpate for a thrill over the fistula To assess for patency in a dialysis fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. Remember, that you "feel" a "thrill." The other options are unrelated to evaluating patency.

The nurse is caring for a client in the coronary care unit who has developed acute renal failure as a consequence of cardiogenic shock. Which of the following findings are consistent with the diagnosis? (Select all that apply.) Pitting sacral edema Jugular vein distention Oliguria Crackles on auscultation in bilateral bases Weight loss

Pitting sacral edema Jugular vein distention Oliguria Crackles on auscultation in bilateral bases Findings related to fluid retention and heart failure are expected, because the kidneys are unable to function properly due to a decrease in glomerular filtration rate and tubular necrosis. In the bed-bound client, pitting sacral edema would be seen, since fluid follows gravity. Weight gain, jugular vein distention, oliguria and crackles in the lungs would also be expected with fluid overload in this client. Treatment consists of diuresis, with a possible small fluid challenge, if the client can tolerate it, to correct pre-renal azotemia. If these options are not effective or inappropriate for the client, dialysis or ultrafiltration may be used to remove excess fluid. In many cases, this type of treatment is temporary, and can be stopped as the kidney function improves with improved urine output and decreasing creatinine levels.

The nurse is caring for a client in labor. Which of the following situations will most likely put the neonate at risk for sepsis? Premature rupture of membranes Cesarean delivery Precipitous vaginal birth Maternal gestational diabetes

Premature rupture of membranes Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12 to 24 hours of leaking fluid, actions should be taken to reduce the risk of infection to the mother and the fetus/newborn.

Ref # 4363 The nurse is preparing to administer a blood transfusion for a client with anemia secondary to intraoperative blood loss. Which of the following interventions by the nurse will help reduce the risk of complications associated with the transfusion? (Select all that apply.) Prime the intravenous tubing with dextrose solution (D5W) Prior to infusion, check client identification against unit of blood to be transfused Monitor vital signs during blood administration Warm blood in a microwave Verify that a 20-gauge or larger catheter is used

Prime the intravenous tubing with dextrose solution (D5W) Prior to infusion, check client identification against unit of blood to be transfused Verify that a 20-gauge or larger catheter is used

The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted with a connection to a ventilator. Which finding should prompt the nurse to take immediate action to resolve the issue? Client is unable to speak Mist is visible in the T-Piece of the ventilator circuit Pulse oximetry of 86% saturation Breath sounds are heard bilaterally

Pulse oximetry of 86% saturation Pulse oximetry should not be lower than 90% saturation. Breath sounds are heard bilaterally so the placement of an ET is most likely in proper position. The ventilator settings will need to be rechecked. A client with an ET tube in place will not be able to talk when the ET tube balloon is inflated.

A nurse is caring for a 69-year-old diagnosed with hyperglycemia. Which activity or task could be assigned to the unlicensed assistive person (UAP)? Review the initial signs of hyperglycemia with the client's family Check the condition of the skin of the lower extremities Monitor for altered levels of consciousness (LOC) Record dietary intake

Record dietary intake The UAP can perform routine activities with predictable outcomes, such as recording dietary intake. Although the UAP can usually assist clients with personal hygiene and would be able to identify a change in LOC (for example, the client does not respond appropriately to questions), their role is to inform the nurse about changes in the client's condition. The nurse must follow up on this information and perform a focused assessment, communicate changes in the client's condition with the health care team and then develop a revised plan of action for client care.

The client has undergone a dilation and curettage (D & C) following a spontaneous abortion at 8 weeks. To promote an optimal recovery, what information should the nurse include in the discharge teaching? (Select all that apply.) Resume vaginal intercourse 6 weeks after the procedure Referral for grief counseling Strenuous sport activities should be postponed until bleeding stops Use sanitary pads until vaginal bleeding has stopped Expect heavy bleeding for at least a week

Referral for grief counseling Strenuous sport activities should be postponed until bleeding stops Use sanitary pads until vaginal bleeding has stopped Acknowledge that the client has experienced a loss and may want to attend a support group or have professional counseling. Most women experience some painful cramping initially, but it doesn't last long; bleeding can be expected for a few days to up to 2 weeks. The client should be told to avoid vaginal intercourse and not to use tampons for about 2 weeks. Most women can return to normal activities within a day or so but strenuous sport activities should be postponed until the bleeding stops.

The nurse is educating a client about how to use a metered-dose inhaler with spacer. Drag and drop the options below in the order that demonstrates correct use of a metered-dose inhaler with spacer.

Release the medication into the spacer. Breathe in deeply. Remove the mouthpiece, then hold breath for 10 seconds, then breathe out slowly. Spacers are highly recommended when inhalers are used because they increase the availability of the medication to the client.

A nurse is teaching a class for new parents at a local community center. Which activity would the nurse stress as being the most hazardous for an 8 month-old? Jumping on a bed Eating whole peanuts Playing around electrical outlets Riding in a car

Riding in a car Car accidents are a leading cause of death in babies and children, as well as a major cause of permanent brain damage and spinal cord injury. Although all the other options pose a danger to young children, drowning is actually the second most common cause of accidental death among children.

The nurse discovers that a chest tube has become disconnected from the main connection site of a closed chest drainage unit (CDU). What immediate action should be taken by the nurse? Cover the insertion site with a sterile petroleum gauze pad Submerge the distal end of the tube in 2 - 4 centimeters of sterile water Reconnect the drainage tube to the chest tube Clamp the chest tube nearest to the client with a rubber-tipped hemostat

Submerge the distal end of the tube in 2 - 4 centimeters of sterile water If the tube becomes disconnected from the main connection site of a CDU, the nurse should place the end of the chest tube in a bottle of sterile water (or saline solution) while someone else prepares a new CDU setup. The health care provider should be called (the nurse should expect an order for a chest X-ray.) To prevent the chest tube from coming apart, it's important to spiral-tape the main connection site and not to let loops of tubing hang down the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or tension pneumothorax. Only if the chest tube becomes dislodged from the client does the nurse need to cover the insertion site with a sterile gauze dressing.

The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true about tardive dyskinesia? TD more commonly develops in children and young adults diagnosed with Tourette syndrome TD occurs within minutes of the first dose of any antipsychotic drug but it is reversible TD can occur in clients taking antipsychotic drugs longer than two years TD can easily be treated with anticholinergic drugs

TD can occur in clients taking antipsychotic drugs longer than two years Tardive dyskinesia (TD) is an extrapyramidal side effect that appears after prolonged treatment with antipsychotic medication. Early symptoms of TD are fasciculations of the tongue or constant smacking of the lips. Neuroleptic malignant syndrome is a more serious side effect of antipsychotic medications in which the client presents with hyperthermia, rigidity, and autonomic dysregulation (hypertension, tachycardia, tachypnea, agitation, diaphoresis). TD can be treated with the anticholinergic medication benztropine; therapy is started with a low dose and gradually increased to find the smallest amount necessary for relief. Tourette syndrome is a movement disorder, but it is unrelated to TD.

A nurse is teaching about nonsteroidal anti-inflammatory agents (NSAIDs) to a group of clients diagnosed with arthritis. The nurse should emphasize which of these actions to minimize a side effect of these drugs? Continue to take aspirin for short-term pain relief Use alcohol in moderation when driving or operating heavy machinery Take the medication after meals or with food Report joint stiffness in the morning

Taking NSAIDs after meals or with food should help to minimize gastric irritation. The client should also take the medication with a full glass of water and remain in an upright position for 15 to 30 minutes after administration. Clients should be cautioned to avoid concurrent use of aspirin or alcohol with these medications to minimize possible gastric irritation; three or more glasses of alcohol per day may increase the risk of GI bleeding.

The nurse is discharging a client after a laparoscopic cholecystectomy. Which finding should the client be instructed to report to the primary care provider? Temperature of 101 F (38.3 C) Seeing spots of blood on the Band-Aids® Experiencing shoulder pain Decrease in appetite

Temperature of 101 F (38.3 C) Laparoscopic surgery allows quick discharge and recovery. However, clients need to know what to expect and which postop discomforts are reportable. A temperature of 101 F (38.3 C) and above may signal infection and should be reported. The other listed symptoms are expected after this surgery. Shoulder pain (ranging from mild to severe) is due to the CO2 gas injected during surgery; it will dissipate within days. Band-Aids or other small dressings will be placed over the small incision sites and may have some spots of blood on them. It may take a day or two before appetite returns to normal.

A client's admission urinalysis shows the specific gravity value of 1.039. Which of these findings would the nurse expect to find during the physical assessment of this client? Above normal heart rate Moist mucous membranes Poor skin turgor Increased blood pressure

The specific gravity value is high, which would indicate dehydration. Specific gravity measures urine density and an average urine specific gravity value is around 1.020. Poor skin turgor, as seen with tenting of the skin, is consistent with this problem.

A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of voiding on the floor by which of these approaches? Require the client to mop the floor after each incident Restrict the client's fluids throughout the day Toilet the client more frequently with supervision Withhold privileges each time the voiding occurs

Toilet the client more frequently with supervision With a client that has altered thought processes, the appropriate nursing approach to change behaviors is to take an active role in attending to the physical needs of the client. The other options are incorrect approaches.

A nurse is assessing a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dL. Which approach to therapy should the nurse anticipate? Additional potassium via IV administration Serum lipase levels every 12 hours Total parenteral nutrition (TPN) via central line Blood for coagulation studies daily

Total parenteral nutrition (TPN) via central line The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. A normal total serum protein level is 6.0-8.0 g/dL. Total parenteral nutrition is a mixture of dextrose, amino acids, lipids, electrolytes, vitamins and minerals that is administered intravenously to patients who cannot receive all of their nutritional needs via the enteral route. TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately, which is necessary for proper healing to occur.

The RN, who is functioning as the charge nurse, needs to determine shift assignments. How will the charge nurse determine which client assignments are appropriate for the licensed practical nurse (LPN)? a. Ask the LPN about prior experience caring for clients with similar diagnoses b. Determine how many nursing assistants are available to help the LPN with client care c. Refer to the list of technical tasks LPNs are trained to perform d. Review the procedure manual with the LPN prior to making an assignment

a. Ask the LPN about prior experience caring for clients with similar diagnoses The definition of assignment is the routine care, activities and procedures that are within the authorized scope of practice of the RN or LPN/LVN. The RN must determine the needs of the clients and make assignments not only based on scope of practice, but also education, demonstrated competency and skill level. Regardless if the LPN received education and training to perform specific skills, the RN needs to determine the LPN's experience with caring for clients with similar diagnoses. While the RN is responsible for ensuring an assignment given to a delegatee is carried out completely and correctly, the LPN must be able to perform the skills or tasks independently.

The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for as long as three hours, and has had several shaking spells. Which immunization would the nurse expect to be primarily responsible with these findings? a. DTaP b. IPV c. Hepatitis B d. HIB

a. DTaP DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough). The majority of reactions described in this question occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose, as well as signs of encephalopathy within seven days of the immunization.

The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? a. PaCO2 30 mm Hg b. Hemoglobin 15 g/dL (150 g//L) c. Sodium 130 mEq/L (130 mmol/L) d. Chloride 100 mEq/L (100 mmol/L)

a. PaCO2 30 mm Hg Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease in PaCO2 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both males and females. The chloride and sodium results are also WNL.

Which individual is at greatest risk for the development of hypertension? a. 40 year-old Caucasian nurse b. 60 year-old Asian-American shop owner c. 45 year-old African-American attorney d. 55 year-old Hispanic teacher

c. 45 year-old African-American attorney The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising.

The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after treatment for chronic renal disease. Which serum lab data should receive priority attention by the nurse? a. Osmolality and sodium b. Blood urea nitrogen and magnesium c. Calcium and phosphorus d. Glucose and potassium

c. Calcium and phosphorus The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous levels will be elevated in hyperfunction of this gland until the client is stabilized. To recall this information think of a see-saw. Associate that calcium is first in the alphabet and thus calcium follows the direction of the abnormality - hyper or hypo function - of the parathyroid. Put the calcium on one side and the phosphorus on the other side of the see-saw.

A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? a. Weight reduction b. Stress management c. Smoking cessation d. Physical exercise

c. Smoking cessation Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time.

The nurse is working with victims of domestic abuse. The nurse should understand which of these factors is a reason why domestic violence or emotional abuse remains extensively undetected? a. The expenses due to police and court costs are prohibitive b. Little knowledge is known about batterers and battering relationships c. There are typically many series of minor, vague complain d. Few people who have been battered seek medical care

c. There are typically many series of minor, vague complain Signs of domestic violence or emotional abuse may not be clearly manifested and include many series of a minor complaints such as headache, abdominal pain, insomnia, back pain and dizziness. These may be covert indications of violence or abuse that go undetected. These complaints may be vague and reflect ambivalence about the disclosure of any violence or abuse.

A client diagnosed with angina has been instructed about the use of sublingual nitroglycerin. Which statement made by the client is incorrect and indicates a need for further teaching? a. "I'll call the health care provider if pain continues after three tablets five minutes apart." b. "I will rest briefly right after taking one tablet." c. "I understand that the medication should be kept in the dark bottle." d. "I can swallow two or three tablets at once if I have severe pain."

d. "I can swallow two or three tablets at once if I have severe pain." Clients must understand that just one sublingual tablet should be taken at a time and placed under the tongue. After rest and a five-minute interval, a second and then eventually a third tablet may be necessary.

A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? a. Advise the client to have someone bring her to the emergency room as soon as possible b. Ask the client to explain what she has taken and how often, and then evaluate other specific complaints c. Advise the client that the swings in her hormones may be the problem; suggest that she call her health care provider d. Ask the client to stay on the line, get the address, and send an ambulance to the home

d. Ask the client to stay on the line, get the address, and send an ambulance to the home The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery.

The nurse is caring for a client who just had a central venous catheter line inserted at the bedside. Which of these assessments requires immediate attention by the nurse? a. Pallor in the extremities b. Increased temperature by one degree c. Involuntary coughing spells d. Dyspnea at rest

d. Dyspnea at rest Complications of central catheter insertion include pneumothorax and hemothorax. Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other potential complications of central catheters may include thrombosis, local or systemic infection, or even cardiac tamponade (if the central line perforates the heart). When considering the options listed, the client who is dyspneic after central line insertion would be the greatest concern for the nurse.