NCLEX/HESI Comprehensive

A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation. The child asks the nurse " why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?

" To protect you because you can get an infection very easily Reverse isolation precaution implement measures to protect the client from exposure to microorganisms from others (B). Although microbes are prevalent in all environments, (A) does not adequately answer the child's question. Reverse isolation should be implemented until the client's white blood cell increases (C). Neutropenia in this child does not place others (D) at risk for infection.

A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply.

"I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?

"I need to contact my surgeon immediately if I feel any numbness in my genital area."

An older client who is admitted with terminal cancer...

"I notice you have a Bible"

A nurse provides information about smoking-cessation measures to a client diagnosed with coronary artery disease (CAD). Which statement by the client indicates a need for further information?

"I should drink a cup (235 ml) of coffee if I feel the urge to smoke."

A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information?

"I should drink a cup of coffee if I feel the urge to smoke."

A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction?

"It's best to use cow's milk, as long as it's whole milk and not skim."

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse?

"Let's talk about the information that you need to determine your risk of contracting HIV."

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse?

"Let's talk about the information that you need to determine your risk of contracting HIV." Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once the results of a pregnancy test have been obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that avoid the client's concern.

A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

"Tell me more about what you're feeling."

A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate?

"Tell me more about your concerns regarding the tube feedings."

A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?

"Wearing the brace is really important in curing the scoliosis."

A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?

"Wearing the brace is really important in curing the scoliosis." Rationale: Scoliosis is a lateral curvature of the spine. Bracing is not curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown.

A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?

"What are your feelings right now?"

A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?

"What are your feelings right now?" Rationale: Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. "You aren't talking today. Cat got your tongue?" is a nontherapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and non-therapeutic.

A nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply.

*"I need to avoid salt in my diet." *"It's fine to take any over-the-counter medication with the lithium." *"Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet? Select all that apply.

*Smoking *High alcohol intake *White or Asian ethnicity

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.

*Spinach *Legumes *Whole grains

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.

*Tachycardia *Diminished peripheral pulses

A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin 0.25 mg in the treatment of heart failure (HF). Which instructions should the nurse include on the list? Select all that apply.

*Take your pulse before taking each dose. *Take the digoxin at the same time each day. *Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances.

A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest.

1 Possible infection 2 Decreased nutrition 3 Fatigue 4 Despair

The nurse cares for an 84-year-old man who appears disheveled, restless and confused. The nurse prepares to administer medication and observes that the client's armband is missing. Which is the MOST appropriate action for the nurse to take? 1. Ask the client's roommate to identify the client. 2. Ask the client to state his name. 3. Ask another nurse to identify the client. 4. Look in the chart at the picture of the client.

1) Implementation: outcome not desired; "passing the buck;" mental status of roommate unknown 2) Implementation: outcome not desired; client confused 3) Implementation: outcome not desired; "passing the buck"; must check identification 4) CORRECT - Implementation: outcome desired; only way to positively identify client

The nurse cares for clients on an acute-care surgical area. Which client should the nurse see FIRST? 1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest drainage system. 2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden). 3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday. 4. A client who had an ileostomy 3 days ago complains of "aching legs."

1) Not priority; further assessment required; see second 2) Not priority; may be safety issue; further assessment needed; see last 3) CORRECT-Priority; may have decreased cerebral blood flow or oxygenation; see first 4) Not priority; client is at risk for thrombophlebitis; further assessment and evaluation needed; see third

A nurse is presented with a group of clients in the emergency room. The nurse knows that which of the following clients needs immediate attention? 1. A child who is bleeding from a facial injury. 2. A middle-aged client with midsternal chest pain. 3. A middle-aged client in respiratory distress. 4. An infant who has been vomiting for 8 hours.

1) Not usually life-threatening 2) Could be angina; see second 3) CORRECT-Most unstable client; check airway, breathing (ABCs) 4) Potential for dehydration; needs further assessment; should not see first

Preoperatively, a client is to receive 75mg of meperidine (demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?

1.5 mL To correctly solve this problem, use the formula: Desired/On Hand, or the algebraic formula: 75: x = 50 : 1. 50x = 75. x = 75/50 or reduced to 1.5 mL (C).

A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period?

1670mL

Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication:

2 hours after meals

Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication:

2 hours after meals

A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion?

25 gtt/min

A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client?

28 mm Hg

The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 mL vial is labeled "Mucomyst 20% solution (20 grams/100 mL)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.)

3 20 grams is equivalent to 20,000 mg. 20,000 mg/100 mL = 200 mg/1 mL. Using Desired/Have X Volume: 600 mg/200 mg X 1 mL = 3 mL.

Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:

3 minutes

Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:

3 minutes Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period.

A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. The nurse ensures that:

30-degree flexion of the client's elbow is maintained when the client is holding the cane

An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.? Type your answer in the space provided.

350mL

A nurse is caring for a client who sustained burn injuries on the anterior lower legs and anterior thorax. What percentage of the client's body, according to the Rule of Nines, has been affected?

36%

A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

61 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour

Which individual may legally sign an informed consent?

A 16-year-old mother for her newborn

the nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select?

A Buretrol Attachment A buretrol attachment is used to restrict the total volume of IV fluids that a client receives (D). (A and B) control the rate of administration, but not the total volume infused. (C) reduces the risk of infusion of particulates but does not control the volume infused.

A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note?

A blood pressure higher than the normal range

A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and a nursing assistant on the team. Which client is the appropriate choice for the nursing assistant?

A client with rheumatoid arthritis who needs assistance with feeding and ambulation

A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and a unlicensed assistive personned (UAP) on the team. Which client is the appropriate choice for the UAP?

A client with rheumatoid arthritis who needs assistance with feeding and ambulation

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note?

A diagram of ulcers, stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister.

A male client calls the crisis center and tells the nurse...

A loaded gun.

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:

A lower abdominal incision

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:

A lower abdominal incision Rationale: A lower abdominal incision is used in suprapubic or retropubic prostatectomy. An upper abdominal incision is not used to remove the prostate. An incision between the scrotum and anus is made when a perineal prostatectomy is performed. Transurethral resection is performed through the urethra; an instrument called a resectoscope is used to cut the tissue by means of a high-frequency current.

A client with cellulitis is recovering at home after experiencing a severe reaction

A malpractice suit based on lack of reasonable and prudent care

A client is comatose upon arrival to the emergency room department after falling from the roof. The client flexes with painful stimuli, and the nurse determines the client"s Glasgow Coma Scale is 6. Which intervention should the nurse prepare to implement to maintain the client"s airway?

A nasopharyngeal tube

The nurse is obtaining a client's consent for a paracentesis...

A needle is inserted to remove excessive fluid from the abdominal peritoneal cavity.

Which evidence support the application of healthcare informatics

A new sense of order to a problem that facilitates cost-effective analysis and evaluation of care

A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider?

A rigid, boardlike abdomen.

Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio?

A self evaluation that identifies how the nurse has met professional objectives and goals. A clinical portfolio should include pertinent information that assists in providing a comprehensive view of the employee's performance. A self-evaluation (D) provides an important assessment of the nurse's strengths, weaknesses, and progress toward the achievement of professional goals. (A) is not pertinent nor useful evaluative data regarding current performance. While documentation of continuing education and any certifications achieved are important to include in a clinical portfolio, (B) is not necessary. (C) is not a significant component of a clinical portfolio.

A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred?

A sudden gush of dark blood from the introitus

7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? A. Contacting the physician B. Documenting the findings C. Checking the fluid for protein D. Continuing to monitor the client and the FHR

A. Contacting the physician Correct

The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to explain the diagnosis. The nurse tells the mother that in this condition:

Abdominal contents herniate through an opening of the diaphragm

The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?

Activity intolerance related to postoperative pain Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate in learning, so the nursing diagnosis in (A) indicates a need to postpone teaching. (B, C, and D) indicate a need for instruction.

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

Administer the antihypertensive with a small sip of water

A client is receiving atonal (tenormin) 25 mg PO after a myocardial infraction. The nurse determines the clinents apical pulse is 65 beats per minute. What action should the nurse implement next?

Administer the medication Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time.

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?

Administering 100% oxygen

The nurse places a heating pad on the lower leg..

All elements are present to find the nurse liable for damages

An adolescent female who lost fifty pounds...

Amenorrhea

The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?

An African-American Client may have slightly yellow sclerae. Recognizing normal variations that are common in different racial groups helps the nurse differentiate an early sign of pathology, such as yellow sclerae. A slightly yellow color of the sclera for (C) is a normal racial variation found in the African-American population. (A, B, and D) are findings not related to one racial group.

A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result?

An increase in muscle strength

49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer.

Answer: __ Correct Responses: "1"____ Nursing Progress Notes 1. Hyperreflexia is present. 2. Urinary protein is not detectable. 3. Urine output is 45 mL/hr. 4. Blood pressure is 128/78 mm Hg.

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?

Anxiety

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?

Anxiety

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?

Anxiety Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health.

A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital sign must be checked before the medication is administered?

Apical pulse

A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should:

Ask the answering service to contact the on-call physician

To assess a client's pupillary response to accommodation, a nurse should perform which activity?

Ask the client to look at a distant object and then at an object held 10 cm from the nose. To check the accommodation response, the client should gaze and fixate on an object 2 to 3 feet away, then bring the object closer until the client is fixated on the object at 6 to 8 inches (10 cm) and identify pupillary constriction as the client focuses on the near object (D). (A and B) evaluate pupillary reactivity to light (PERL). (C) evaluates pupil and blink reflexes (Cranial Nerve III).

The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?

Ask the spouse to step out for a few minutes. The nurse should ask the spouse to step out of the room (D), which maintains the client's privacy and allows the client to respond, without confronting the spouse. (A) reinforces the spouse's responses. (B) may not eliminate the spouse's responses on behalf of the client. (C) does not foster the nurse-client relationship.

A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate?

Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain

Three days after a colon resection, the nurse is assessing a client with a NGT...

Aspirate the tube contents to test the pH

A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor for the risk of which complication?

Aspiration pneumonia.

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement?

Assess the client's needs for food, liquids, and rest.

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to:

Assist in intubating the client and beginning mechanical ventilation

3-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: A. Call the nursing supervisor B. Ask the answering service to contact the on-call physician C. Withhold the medication until the physician can be reached in the morning D. Administer the medication but consult the physician when he becomes available

B. Ask the answering service to contact the on-call physician

4.An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: A. Documenting the findings B. Asking the ED physician to check the client C. Continuing to monitor the client's cardiac status D. Informing the client that PVCs are expected after an MI

B. Asking the ED physician to check the client

42 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: A. Check the client's vital signs B. Check for the presence of a gag reflex C. Assess the client for the presence of bowel sounds D. Ask the client to gargle with a warm saline solution

B. Check for the presence of a gag reflex

99 -A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note? A. B. C. D.

B. Correct

80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: A. June 2, 2013 B. July 2, 2013 C. October 2, 2013 D. September 18, 2013

B. July 2, 2013

89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? A. Frequent suctioning B. Maintaining cuff pressure C. Maintaining mechanical ventilation settings D. Alternating the use of a cuffed tube with a cuffless tube on a daily basis

B. Maintaining cuff pressure

24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? A. Clear and yellow B. Thick and opaque C. White and odorless D. Clear, with a foul odor

B. Thick and opaque

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply.

Beer Yogurt Pickled herring

A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply.

Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event

A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?

Bilateral lung wheezes

A nurse is assessing a client who has been taking amantadine hydrochloride for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?

Bilateral lung wheezes Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system (CNS). The medication is used to treat rigidity and akinesia. Insomnia and orthostatic hypotension are side effects of the medication. Adverse effects include congestive heart failure (evidenced by bilateral lung wheezes), leukopenia, neutropenia, hyperexcitability, convulsions, and ventricular dysrhythmias.

A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely?

Bleeding

A client is receiving an intravenous infusion of alteplase. For which adverse effect of the medication does the nurse monitor the client most closely?

Bleeding

A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion?

Blood pressure

65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? A. "My child will need to do exercises." B. "My child needs to wear the brace 18 to 23 hours per day." C. "Wearing the brace is really important in curing the scoliosis." D. "I need to check my child's skin under the brace to be sure it doesn't break down."

C. "Wearing the brace is really important in curing the scoliosis."

43 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? A. Inability to cope B. Decreased nutrition C. Decreased fluid volume D. Inability to tolerate activity

C. Decreased fluid volume

83 -Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? A. Nulliparity B. Early menarche C. Multiple sexual partners Correct D. Hormone-replacement therapy

C. Multiple sexual partners

74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? A. Increased platelet count B. Shortened prothrombin time C. Positive result on d-dimer study D. Decreased fibrin-degradation products

C. Positive result on d-dimer study

15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? A. The client has a history of cataracts. B. The client has a history of hypothyroidism. C. The client takes a prescribed antihypertensive. D. The client is allergic to acetylsalicylic acid (aspirin).

C. The client takes a prescribed antihypertensive.

48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: A. Sodium intake is restricted B. Fluid intake must be limited to 1 quart each day C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period D. Urinary protein must be measured and that the physician should be notified if the results indicate a trace amount of protein

C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period

84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? A. Umbilical cord compression B. Pressure on the fetal head during a contraction C. Uteroplacental insufficiency during a contraction Correct D. Inadequate pacemaker activity of the fetal heart

C. Uteroplacental insufficiency during a contraction

The nurse is reviewing the lab results of an older client who is admitted to a medical unit, Which serum chemistry values should the nurse recognize as most commonly affected by the aging process?

Calcium Potassium Sodium

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside?

Calcium gluconate

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available?

Calcium gluconate Rationale: Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures (eclampsia). It also causes central nervous system depression, however, so toxicity is a concern. Calcium gluconate should be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium level becomes too high. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency.

Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to:

Call the health care provider if a fever, sore throat, or muscle aches develop

Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?

Case manager. The role of the case manager (A) is to assist the continuum of care for the client, and coordinate the plan of care, evaluate client needs, and collaborate with the interdisciplinary healthcare team to ensure that goals are met, quality is maintained, and progress toward discharge is made. (B) focuses on staffing and assigning work on client units. (C) reviews research and assesses opportunities for process improvement, implement changes, measure outcomes, and start the improvement process. (D) is responsible for all of the discharge needs of clients at the time of discharge but would not be involved with client admission activities.

Methylergonovine is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication?

Checking the client's blood pressure

Vasopressin (Pitressin) is prescribed to a client with diabetes insipidus. For which sign, indicative of an adverse effect of the medication, does the nurse monitor the client?

Chest pain

What is the largest contributing factor for the increase in the need for home care?

Clients are more acutely ill when discharged from acute care facilities

After eye drops are instilled, which instruction should the nurse provide to the client?

Close your eyelids Gently closing the eyelids (C) without blinking (D) allows the medication to spread over the eye. It is usually helpful for the client to tilt their head back (A) while the eye drops are being instilled. (B) will not assist in medication distribution or absorption.

A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to:

Closely monitor the blood glucose level

An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which finding does the nurse expect to note?

Complaints of inability to close the eye on the affected side

An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note?

Complaints of inability to close the eye on the affected side

The nurse-manager is developing a plan to increase the local population's utilization of a new community-based public clinic. Which approach should the nurse utilize to obtain the most impact on developing a collaborative partnership with the community?

Conduct a focus group in community to gather data on culturally significant needs

The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?

Confidentiality Confidentiality (D) is the nurse's primary responsibility and is supported by HIPAA, which mandates that personal information is not disclosed and access to sensitive client information is limited. Caring (A) involves the nurse's concern about how the client experiences the world. Veracity (B) is the nurse's duty to tell the truth and not deceive others. Advocacy (C) is support of the client's best interests.

A nurse is monitoring a client receiving terbutaline by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:

Contacting the health care provider Rationale: Terbutaline may be used to stop preterm labor. It stimulates beta-adrenergic receptors of the sympathetic nervous system, resulting in bronchodilation and inhibition of uterine muscle activity. The nurse monitors the client for adverse effects and notifies the health care provider if the maternal heart rate is faster than 110 beats/min, respiration is faster than 24 breaths/min, systolic blood pressure is less than 90 mm Hg, the fetal heart rate is faster than 160 beats/min, or the client complains of chest pain or dyspnea. Increasing the rate of infusion and continuing to monitor the client and are inappropriate and delay necessary interventions. Although the nurse would document the findings, the most appropriate action in this scenario is to contact the health care provider.

The nurse is assessing a child of Chinese descent who arrives in the clinic

Cupping to remove colds and coughs

95- A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: A. Continue monitoring the client B. Increase the amount of humidified oxygen C. Continue administering humidified oxygen D. Assist in intubating the client and beginning mechanical ventilation

D. Assist in intubating the client and beginning mechanical ventilation

101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? A. Cough B. Fatigue and lethargy C. Dizziness and fatigue D. Numbness and tingling of the fingers or toes

D. Numbness and tingling of the fingers or toes

105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client: A. That driving is prohibited while the client is taking the medication B. To take the medication immediately if the desire to drink alcohol occurs C. That the effect of the medication ends as soon as the client stops taking the medication D. That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol

D. That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol

44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: A. The sex of the fetus B. Genetic characteristics C. An accurate age for the fetus D. The degree of fetal lung maturity

D. The degree of fetal lung maturity

A female client who is diagnosed with an eating disorder...

Dance and movement therapy

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician?

Dark urine

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the health care provider?

Dark urine Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency, and decreased appetite are side effects of the medication.

Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?

Deal with issues and not personalities. Dealing with the issues which are concrete, not personalities (A) which include emotional reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not resolve the conflict when diverse opinions are expressed emotionally.

A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:

Decrease

Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple?

Diagnostic testing may indicate a fetal problem that could be treated prior to delivery. Although the couple is opposed to abortion, prenatal testing may reveal a fetal disorder that is treatable in utero or immediately after birth with favorable results (C). (A) is not an due to the couple's stated opposition. Prenatal testing has value beyond termination (B) because it provides knowledge and time for the couple to prepare for various possibilities. Prenatal testing is voluntary

During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? a."I will need to eat 600 more calories per day because I am pregnant." b."I can continue with the same diet as before pregnancy as long as it is well balanced." c."Diet and insulin needs change during pregnancy." d."I will plan my diet based on the results of urine glucose testing."

Diet and insulin needs will change significantly throughout my pregnancy.

The nurse is supervising a UAP who is feeding....

Divides solid food items into one inch cube pieces.

A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement?

Document a possible Type I latex allergy.

A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:

Document the findings

A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:

Document the findings

A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, the nurse should:

Document the findings

A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:

Document the findings

The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:

Document the laboratory result in the client's record

The nurse is suctioning the trach for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting?

Each pass of the suction catheter should take no longer than five seconds.

The nurse identifies a clients needs and formulates th nursing problem of " Imbalancee nutrition: Less than body requirements, related to mental impairment and decreased intkae, as evidence by increasing confusion and weight loss of more than 30 pounds over the last 6 months. " which short-term goal is best for this client?

Eat 50% of six small meals each day by the end of the week Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days before discharge. (A) meets those criteria. (B) is nurse-oriented. (C) may be beyond the capabilities of a confused client. (D) is a long-term goal.

An infant who is delivered at 32 weeks gestation arrives in the nursery intubated. After the infant is placed under a radiant warmer with prescribed ventilator settings, the nurse applies a cardiorespiratory monitor and pulse oximeter, which indicates an O2 sat of 80%. What action should the nurse implement first?

Ensure patency of the endotracheal tube.

A nurse in a health care provider's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to see documented in the child's record?

Episodes of cramping abdominal pain and excessive flatus

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client?

Epistaxis

Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate?

Every morning before breakfast, with a full glass of water

An adolescent client is admitted to the mental health unit for impulsivity...

Explain the consequences for breaking the unit rules

A client with CKD receives peritoneal dialysis

Explore options with the regional dialysis center about reducing the cost of home dialysis.

Which components are characteristic of practice context?

Factors and systems that contribute to delivery of nursing care

The nurse identifies a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding?

Failure of the liver to convert ammonia absorbed from the bowel to urea.

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.

Fatigue Low-grade fever

A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as:

Fear

To avoid a false positive result for fecal occult blood in a stool specimen

Fish Beef Vitamin C Tablets Ibuprofen

In which order should the nurse implement these actions when withdrawing a solution from an ampule?

Flick the stem Wrap the neck Break the neck Stabilize the ampule Withdraw the solution

After attending an inservice for bioterrorism preparedness

Flu-like symptoms, gastrointestinal distress, and papular lesions

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented?

Flulike pulmonary symptoms

Which action by the nurse-manager

Fosters positive behavior changes in staff members

A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?

Fowler's Position Rationale: A nasogastric tube is inserted through the nose and into the stomach for the purpose of gastric decompression or feeding the client. The client is placed in the Fowler position before insertion of the tube to promote comfort and easy insertion. A flat position may be used for clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted with the foot of the bed down and may be used to promote gastric emptying or prevent esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the head of the bed down and may be used for postural drainage or to facilitate venous return in clients with poor peripheral perfusion

The nurse is administering a nasogastric tube feeding to a client who is comatose

Gastric residual of 150 ml

The nurse is assessing an adult who displays stagnation,....

Generativity versus stagnation

A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately:

Get into the shower and rinse the skin for at least 15 minutes

A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide?

Headache and hyperirritability are common Withdrawal from nicotine causes cravings, restlessness and hyperirritability, headache (B), insomnia, depression, decreased blood pressure, and increased appetite. Nicotine is a highly addictive substance that precipitates an intense withdrawal syndrome, not (A). Nicotine causes vasoconstriction which increases peripheral resistance and blood pressure (C), but withdrawal is likely to relax peripheral blood vessels and reduce blood pressure. Many individuals experience an increased appetite, not (D).

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate by way of the nasal route. For which occurrence does the nurse tell the client to contact the health care provider?

Headache and nausea

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test:

Helps predict the risk for the development of chronic complications of diabetes mellitus

The nurse is providing tracheostomy care for a client who has encrusted secretions...

Hydrogen peroxide

A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder?

Hypersensitivity to negative evaluation

The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?

Hyperthyroidism Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).

The nurse-manager is planning to study

Identification Review Implementation Identify and develop

A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially:

Identify the client's treatment goals

During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first?

Identify the problem. The sequential steps in problem-solving are to first identify the problem (B), then consider alternatives (C), consider outcomes of the alternatives (D), predict the likelihood of the outcomes occurring, and choose the alternative with the best chance of success (A).

A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting:

Improved swallowing function

Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the client that it is best to take it:

In the morning, before 9:00 a.m.

A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for hypothyroidism. The nurse tells the client that it is best to take the medication:

In the morning, before breakfast

A nurse provides instructions to a client who will be taking levothyroxine for hypothyroidism. The nurse tells the client that it is best to take the medication:

In the morning, before breakfast

A male client tells the nurse that he is frequently constipated

Inadequate intake of dietary fiber and fluids

The nurse determines that a clients body weight is 105A% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, " Imbalanced nutrition: More than body requirements ? "

Inadequate lifesyle changes in diet and exercise Obesity is a body weight that is 20% above desirable weight for a person's age, sex, height, body build, and calculated body mass index (BMI). (C) best identifies factors that contribute to the formulation of the nursing diagnosis. (A and B) are medical classifications for a client's weight. Although the client is at an increased risk for several chronic illnesses (D), such as heart disease, diabetes mellitus, hypertension, coronary artery disease and hyperlipidemia, this is not a contributing cause or related factor that supports the nursing diagnosis.

A client diagnosed with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to:

Increase intake of high-fiber foods

A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to:

Increase intake of high-fiber foods

A nurse is monitoring a child with intussusception for signs of peritonitis. For which finding, indicative of this complication, does the nurse notify the health care provider?

Increased heart rate

A nurse is monitoring a child with intussusception for signs of peritonitis. For which of the following findings, indicative of this complication, does the nurse notify the physician?

Increased heart rate

In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition?

Increased thirst. (A) is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he or she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, (B) is not an appropriate measure of dehydration for a 3-year-old. The skin of a child with diabetes insipidus is usually warm and dry, not (C). (D) is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome.

The nurse is catheterizing a 7 yr old boy who has been admitted to the peds unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort?

Insert 5 ml of 2% lidocaine lubricant into the urethra.

A client is prescribed a STAT dose of IV insulin...

Insulin regular (Humulin R)

A client diagnosed with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B. Which parameter does the nurse check to detect the most common adverse effect of this medication?

Intake and output

A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication?

Intake and output

Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while she is taking the medication?

Intake and output

A nurse is preparing to provide information to a client who has been found to have stable angina. The nurse plans to tell the client that this type of angina:

Is often managed medically with medications such as calcium channel blockers and beta-blocking medications

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is:

July 2, 2013

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply.

Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short

The nurse is caring for a client with diabetic ketoacidosis

Kussmaul respirations

A pediatric nurse is caring for a hospitalized toddler. Which activity does the nurse deem the most appropriate for the toddler?

Large building blocks

Although previously well controlled with glyburide (Diabeta), a client's fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia?

Lithium carbonate (Lithobid)

Although previously well controlled with glyburide, a client's fasting blood glucose has been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia?

Lithium carbonate (Lithobid)

Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose?

Maintaining the client on bed rest for 3 hours

The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?

Medication administration. In developing organizational skills, medication administration is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be the priority in scheduling nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes precedence in providing care, the client's PRN need is less amenable to a preselected schedule. (B and C) can be scheduled around time-sensitive delivery of care.

A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?

Monitor for increased blood pressure and pulse Clients with alcohol dependency experience withdrawal symptoms, which include elevated blood pressure, pulse, and temperature, so (B) has the highest priority. (A) will prevent Korsakoff's syndrome (secondary dementia caused by thiamine deficiency, associated with malnutrition secondary to excessive alcohol intake), but this intervention does not have the priority of (B). (C and D) are important for alcohol detoxification, but do not have the priority of (B).

Upon admission, the nurse determines a male client with alcohol withdrawal syndrome...

Monitor vital signs

Which assessment finding should the nurse identify in an adult client with sleep deprivation?

Mood swings and irritability

a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map?

Multisicipilinary group In a multidisciplinary work group (B), a number of individuals from a variety of disciplines are involved in developing the care map, but each works independently to implement the care plan. Single-discipline work groups (C), such as (A or D), are likely to focus on the aspects of the care map related only to their specific discipline.

A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?

Nasal cannula. (C) will provide oxygen without covering the client's face. (A and B) are also masks and will not alleviate the problem of feeling "smothered." (D) is used for medication administration rather than oxygen.

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply.

Nausea Eye pain Vomiting Headache

An emergency department nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. The nurse most appropriately:

Notifies the emergency department health care provider

A nurse gives a client a narcotic for pain and must now leave the unit

Nurse-manager

The nurse is caring for a client who is one-day post cardiac catheterization with stent placement

Obtain urine output for the past 4 hours.

A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?

One chronic and one acute illness The plan of care should include goals that are specific for chronic and acute illnesses. Adult-onset diabetes is a life-long chronic disease, whereas influenza is an acute illness with a short term duration (C). (A, B, and D) do not include the correct duration categories for this situation.

The nurse manager is explaining to a new nurse that the nursing units

Operational shared governance

A client is found to have iron-deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells the client that it is best to take the medication with:

Orange juice

A client is found to have iron-deficiency anemia, and ferrous sulfate is prescribed. The nurse tells the client that it is best to take the medication with:

Orange juice

At what phase of the therapuetic relationship...

Orientation phase

A nurse admitting a newborn to the nursery notes that the health care provider has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are:

Outside the abdominal cavity, not covered with a sac

A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are:

Outside the abdominal cavity, not covered with a sac

A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside?

Oxygen cannula and flowmeter

Two hours after vaginal devilry of a 7-pound 3 ounces infant, a clients fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?

Palpate above the symphysis for the bladder. Two hours after giving birth, the uterus should be firm, in the midline, and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder, so palpating for a full bladder above the symphysis (B) should be implemented first. (A, C, and D) are implemented after the client voids or the bladder is emptied by catheterization.

A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid:

Palpating the abdomen

A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis?

Pao2 of 49 mm Hg, Paco2 of 32 mm Hg

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client?

Paresthesia

The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. what is the priority expected outcome for these classes?

Participants can identify at least three coping strategies to use during labor An expected outcome is a specific, measurable change in a client's status that occurs in response to nursing interventions. (B) meets the criteria for an expected outcome. (A, C, and D) are nursing interventions that should lead to the expected outcome.

A client diagnosed with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which response by the nurse is therapeutic?

Perhaps you could attend and talk to the other clients and see what they're drawing and painting." Rationale: The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your health care provider has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern.

On the secound day after admission, a client with a fractures pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism?

Petechiae of the anterior chest wall

A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:

Pitting edema is present Rationale: Edema in the lower extremities reflects pooling of blood, which results in a shift of intravascular fluid into the interstitial spaces. Dehydration is not likely to cause pitting edema. When pressure exerted with a finger or thumb leaves a persistent depression, the client is said to have "pitting edema." Therefore the other options identify incorrect interpretations.

A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell?

Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation. The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation. (A) has nominal effects in hypercyanosis. (C) is self-regulating. (D) is not indicated for immediate relief of tet spells. It is used to improve cardiac output.

Which action should the hospice nurse

Plan regular visits with the client throughout the day

Which nursing diagnosis is best to formulate for a 76-year-old client...

Powerlessness

The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who id in the first trimester of pregnancy . which action should the nurse prepare the client for?

Preparing for other diagnostic testing The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal defects. An elevated result may be a false indicator, so other tests are indicated (B). (A) is not necessary or helpful. Elevated results warrant further testing with ultrasound or amniocentesis before initiating (C or D).

The nurse notes a client with decreased alertness is having difficulty managing saliva

Presence of a gag reflex

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?

Primary nursing. Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing (D) is a care delivery model that provides client care by assignment of functions or tasks. Team nursing (A) is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management (C) is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes.

During a mass casualty incident

Prioritize care for victims

The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA) which intervention should the nurse include in the plan of care?

Progressive leg exercises to obtain 90-degree flexion Isometric quadriceps setting begins the first day after TKA surgery and progresses to straight-leg raises, then gentle ROM to increase muscle strength until 90-degree knee flexion is obtained (A). Bed rest and immobilization is contraindicated to prevent scar tissue, which limits mobility (C). Active flexion exercises through the use of a continuous passive motion (CPM) machine postoperatively promotes joint mobility. Postoperative exercise progresses to full weight-bearing before discharge, but not the first postoperative day (B). Joint mobility is a priority outcome, and dislocation is not typical with TKA (D).

A client is admitted with myasthenia gravis

Ptosis

The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?

Purplish-red pinpoint lesions of the skin Petechiae are described as purplish to red, non-blanchable, pinpoint lesions (A) that are tiny hemorrhages within the dermal or submucosal layers. (B) describes ecchymosis caused by trauma to the underlying blood vessels. (C) describes pustules. (D) is nonspecific and incomplete.

Before administering timolol maleate (Timoptic)....

Receives carvedilol (Coreg) for heart failure (HF)

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:

Recheck the temperature in 4 hours Rationale: A temperature of 100.4° F (38° C) is common during the 24 hours after childbirth and may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for more than 24 hours or exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. The nurse would recheck the temperature in 4 hours. There is no reason to restrict place the client to strict bedrest or to notify the health care provider. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature.

A client is receiving an opioid analgesic every 2 hours for intractable pain...

Respiratory acidosis.

A 6 year old child is alert but quiet when brought to the emergency center with periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?

Rhinorrhoea or otorrhoea with halo sign Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries.

A client is being admitted to the medical unit form the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?

Rubber-tipped clamps Rubber-tipped clamps (C) should be kept at the client's bedside for assessment of possible chest tube air leaks, with the prescription of the healthcare provider. (A), used during a respiratory or cardiac arrest, does not need to be brought to the client's room as a routine precaution. (B) is used to intubate a client and is not indicated for routine care of the client with a chest tube. (D) is indicated by the client's oxygen saturation or arterial blood gases, and is not routinely placed in the room of a client with a chest tube.

When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

S1 Murmur auscultated in supine position. Documentation of subjective and objective data obtained from the physical assessment should be communicated using precise, descriptive, clear, and accurate information, such as auscultated heart sounds while the client is in a specified position (C). (A, B, and D) are nonspecific.

The charge nurse assigns one nurse to care for a client with shingles

Safe and effective care environment

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:

Sardines

Ferrous sulfate is prescribed for a client. The nurse tells the client that it is best to take the medication with:

Scrambled eggs Rationale: Ferrous sulfate is an iron product. Absorption of iron is promoted when the supplement is taken with orange juice or another food source of vitamin C or ascorbic acid. Calcium and phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid.

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply.

Seek medical advice if you find a skin lesion.

A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note?

Serum bicarbonate of 12 mEq/L

The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and insulin

Shakiness

Which information is most important for the nurse to provide parents about long-term care for their child with hydrocephalus and a VP shunt?

Shunt malfunction or infection requires immediate treatment.

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.

Skin tenting Flat neck veins Weak peripheral pulses

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply.

Smoking High alcohol intake White or Asian ethnicity

Pulse oximetry is being used to monitor a client's oxygen saturation

Smoking Jaundice Hypotension Type 1 diabetes mellitus

A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide?

Social smiling begins at approximately 2 months of age.

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client?

Soft, relaxed, nontender uterus

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client?

Soft, relaxed, nontender uterus Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.

Propylthiouracil (PTU) has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which of the following occurrences does the nurse tells the client to contact the physician?

Sore throat

Propylthiouracil has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which occurrence does the nurse tell the client to contact the health care provider?

Sore throat

Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication?

Spinach

Calcium carbonate is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication?

Spinach

A 50-year-old male client with ALS...

Spiritual distress

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?

Spontaneous bruising

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?

Spontaneous bruising Rationale: Missed abortion is the term used to describe when a fetus dies during the first half of pregnancy but is retained in the uterus. When the fetus dies, the early symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish vaginal bleeding may or may not occur. A major complication of a missed abortion is disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should be reported and require further evaluation.

A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description?

Stable

When engaging in planned change on the unit, what should the nurse-manager establish first?

Staff members are aware of the need for change The first step in planned change involves establishing a relationship with those involved in the change process and instilling knowledge and awareness of the need for change (D). The nurse-manager should next implement (C), and then (A and B).

the scope of professional nursing practice is determined by rules promulgated by which organization.?

State's board of nursing The state's Board of Nursing (A) is authorized to promulgate rules and regulations that carry the weight of law. The State Legislature delegates its law-making authority to this administrative law body. (B and C) are influential in defining and describing nursing standards of care, but neither have the authority to pass laws that legally define the professional scope of nursing practice. Although (D) may rule on issues important to nursing practice, the scope of professional nursing practice is determined by the laws, rules, and regulations promulgated by state Boards of Nursing.

A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication?

Steak Rationale: Lovastatin is a lipid-lowering agent. The client is instructed to consume foods that are low in fat, cholesterol, and complex sugars. The item highest in fat here is steak; therefore the client should limit the intake of steak. Fruits, vegetables, and chicken are low in fat.

following an emergency Cesarean delivery the nurse encourages the new mother to breastfed her newborn . the client asks why she should breastfeed now. Which info should the nurse provide?

Stimulate contraction of the uterus When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates the "letdown" reflex, which causes the release of colostrum, and contracts the uterus (C) to prevent uterine hemorrhage. (A and B) do not support the client's need in the immediate period after the emergency delivery. Although maternal-newborn bonding (D) is facilitated by early breastfeeding, the priority is uterine contraction stimulation.

Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?

Supervised and guided visits with infant Structured visits (C) provide an opportunity for the mother and infant to bond and should be facilitated and encouraged according to the client's pace of progress. (A) is unrealistic and may not be safe for the baby or the client. (B) is an unrealistic expectation. Although daily visits may provide support, the significant other may not be able to be there every day (D) based on other family responsibilities.

A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:

Take the medication with food

A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:

Temporarily eases anxiety in the client Rationale: Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. The other options identify interpretations of the client's compulsive behavior.

A nurse is providing home care instructions to a client with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client:

The answer for this question should be something relating to toxicity that may present itself as tinnitus, ie., ringing in the ears.

When administering an intramuscular (IM) injection to an adult client...

The anterosuperior iliac spine and the greater trochanter.

The nurse is conducting a retrospective chart audit to investigate

The benchmark was not met and an action plan should be developed.

A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated?

The client takes isosorbide dinitrate (Isordil).

A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that:

The client's hemoglobin level is low

68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem

The correct answer is A: Protamine . Protamine binds heparin making it ineffective.

85. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently

The correct answer is C: Keep conversations short

19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

The correct answer is D: A preschooler with intermittent episodes of alertness

95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces

The correct answer is D: Have gloves on while handling bedpans with feces

24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

The correct answer is D: I went to the bathroom and my urine looked very red and it didn't hurt when I went.

18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

The correct answer is D: Pupil responses

Levothyroxine (Synthroid) is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the physician's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that:

The full therapeutic effect may take 4 weeks

Levothyroxine is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the health care provider's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that:

The full therapeutic effect may take 4 weeks

A client with osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide?

The infection has walled off into an area of infected bone creating a barrier to antibiotics A sequestrum (dead bone) is separated from the living bone and has no blood supply, so neither antibiotics nor white blood cells can reach the infected area (D). (A and B) do not address the encasement of the necrotic tissue. Although a sinus tract may occur, (C) does not address the purpose of the surgery.

What description encompasses the role in client care management played by nursing informatics?

The input and retrieval of electronic data about a client's medical history

A nurse is assessing a client who is experiencing chest pain. Which observation indicates to the nurse that the pain is most likely a result of angina?

The pain is relieved by rest and nitroglycerin.

A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina?

The pain is relieved by rest and nitroglycerin.

A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?

This anti-estrogen drug inhibits malignancy growth Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women (B), and is classified as a hormonal agent, not (D), used to suppress malignant cell growth.

A client who is taking nitroglycerin for angina is concerned....

This is a common side effect due to the vasodilatory effects of the medication.

A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring?

Thyroid-stimulating hormone (TSH)

Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?

Tolerance of exertion. Awareness of the client's ability to tolerate exertion (D) allows the nurse to plan how to prepare the client for the use of the lift. (A, B and C) are not needed when using a lift.

Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with:

Tomato juice

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?

Tongue protrusion

The nurse is evaluating the external fetal monitor and identifies variable FHR decelerations...

Umbilical cord compression

A male client with gastric cancer is 1 week postoperative....

Vitamin B12

A nurse provides dietary instructions to a client with osteoporosis who has sustained a fracture about foods that will promote healing. The nurse tells the client that it is best to consume foods that are high in:

Vitamin C

The nurse is developing a teaching plan for an adolescent with a milwaukee brace. Which instruction should the nurse include?

Wear the brace over a T-shirt 23 hours a day. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace.

The nurse is assessing a client who is receiving risperidone...

Weight gain

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply.

Weight loss Projectile vomiting Distended upper abdomen

The nurse, auscultating the breath sounds of a client, hears (these sounds.) What are they?

Wheezes

The nurse, auscultating the breath sounds of a client, hears these sounds. What are they?

Wheezes

A nurse is reviewing the laboratory results of a female client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?

White blood cell count of 2.5 × 103/μL (2.5 × 109/L) Rationale: The normal white blood cell count ranges from 4.0-11.0 × 103/μL (4.0-11.0 × 109/L). A white blood cell count of 2.5 × 103/μL (2.5 × 109/L)is low and puts the client at risk for infection. All of the other values are within normal limits. The normal sodium level is 135-145 mEq/L (135-145 mmol/L).. The normal hemoglobin level for a male ranges from 13.2-17.3 g/dL (132-173 g/L). The normal BUN concentration ranges from 6-20 mg/dL (2.1-7.1 mmol/L).

A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?

White blood cell count of 2500 cells/mm3

A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician?

Yellow skin

Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?

You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? (D) acknowledges the stress and encourages the client to discuss options to deal with the problems. Recognizing early signs/symptoms of heightened stress can help to avert a crisis. (A and C) deny the client the opportunity to take control of the problem and use problem solving techniques to resolve the situation. (B) may be offering false reassurance.

Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client

reports decrease in pain Evaluation of effectiveness must indicate if the drug has had the desired effect, in this case, a decrease in pain (A). (B) does not indicate whether the drug was effective, just that it was given. (C and D) do not indicate whether the drug was effective; the client may still be in pain, although talking on the phone or visiting with family members.

The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?

wanting the drug is all that matter to an addict The hallmark characteristic of addiction is impaired control (D): all that matters is obtaining the drug of choice. (A) may or may not be true, but is not the primary characteristic of addiction. (B) is a manifestation of impaired control. Addiction is not caused by being unhappy with one's self, but such unhappiness is usually a result of addiction (C).

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?

"Are you having any difficulty hearing?"

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?

"Are you having any difficulty hearing?" Rationale: Gentamicin sulfate is an aminoglycoside. It inhibits bacterial protein synthesis and has a bactericidal effect. Serious adverse reactions to aminoglycosides include ototoxicity and nephrotoxicity. The nurse must assess the client for changes in hearing, balance, and urine output. The remaining assessment questions are not associated with the adverse effects of this medication.

A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease?

"Do you have episodes of dizziness?"

Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications?

"Does your child have an allergy to peanuts?"

A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse?

"Don't say that. If you can't control yourself, we'll help you."

A hospitalized female client demonstrating mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse?

"Don't say that. If you can't control yourself, we'll help you." Rationale: The nurse should respond using a firm, calm approach, providing the client with clear expectations. The correct option is the only one that involves a firm, calm approach and offers the client help if she needs it. The other three statements challenge the client.

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?

"Have you ever worked in a mine?"

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?

"Have you ever worked in a mine?" Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis.

A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client?

"Have you tested your blood glucose?"

Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction?

"I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."

As a nurse prepares to administer medications to an assigned client, the client asks, "Why don't you just leave me alone?" What is the best response by the nurse?

"I can see that you're upset. Would you like to talk about it?"

A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse?

"I don't think anyone can save the world from the terrorists by himself."

A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?

"I need to contact my surgeon immediately if I feel any numbness in my genital area." Rationale: After radical vulvectomy, the client is instructed to wear support hose for 6 months and to elevate the legs frequently. The client should avoid straining during defecation and should be told that alteration in the direction of urine flow may occur. The client may resume sexual activity in 4 to 6 weeks; the nurse should discuss the possible need for lubrication and position changes during coitus. Genital numbness may be present, but it is not necessary to notify the surgeon immediately if numbness occurs.

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test."

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching?

"I need to eat three meals a day with foods high in protein, fat, and carbs."

A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching?

"I need to eat three meals a day with foods high in protein, fat, and carbs."

A client with type 1 diabetes mellitus is instructed by the health care provider to obtain glucagon hydrochloride for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information?

"I need to give this if he has signs of low blood sugar and goes into a coma."

A client with type 1 diabetes mellitus is instructed by the physician to obtain glucagon hydrochloride (Glucagon) for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information?

"I need to give this if he has signs of low blood sugar and goes into a coma."

A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction?

"I need to keep any unopened bottles of insulin in the freezer."

A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions?

"I need to not drink coffee before the test."

A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction?

"I need to participate in aerobic and weightlifting exercise three times a week."

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?

"I need to stop the medication and call my doctor if I have severe diarrhea."

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?

"I need to stop the medication and call my doctor if I have severe diarrhea." Rationale: Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should maintain a high fluid intake (eight to ten 8-oz [235 ml] glasses of fluid per day) while taking the medication. The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose.

A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction?

"I should eat three meals a day, and the biggest meal should be at suppertime."

A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction?

"I should encourage him to keep his hands hanging at his side when he walks."

Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction?

"I should put ice in my drinks to help soothe the discomfort."

A nurse assigns a nursing assistant to care for a client who is hearing impaired and provides instructions to the nursing assistant about the effective methods for communicating with the client. Which statement by the nursing assistant indicates that further instruction is needed?

"I should raise the volume of my voice and stand on the client's affected side when I'm talking to him."

A nurse assigns a unlicensed assistive personnel (UAP) to care for a client who is hearing impaired and provides instructions to the UAP about the effective methods for communicating with the client. Which statement by the UAP indicates that further instruction is needed?

"I should raise the volume of my voice and stand on the client's affected side when I'm talking to him."

A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction?

"I should use oil-based cosmetics."

The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy?

"I will keep the baby's eyes covered when the baby is under the light." Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infant's eyes should be protected (C) by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not (A), so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose as much skin as possible to the light (D).

A nurse is teaching a client with angina pectoris who is being discharged from the hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching?

"If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work."

A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic?

"Perhaps you could attend and talk to the other clients and see what they're drawing and painting."

A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?

"Tell me about your undergarments so we can discuss how you can have your examination comfortably." It is important that a nurse have respect for the unique qualities that cultural diversity brings to individuals. (D) reflects cultural competence by the nurse and displays respect for the woman's religious practices. The examination may not be able to be modified (A). (B and C) are dictatorial and do not show respect for different cultures or religions.

A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?

"Tell me more about how the medication was making you feel."

A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?

"Tell me more about how the medication was making you feel." Rationale: The correct response acknowledges the client's feelings and opens the channel of communication between the nurse and client. "That's all right. I'd stop, too, if it made me feel funny," indicating approval, is a nontherapeutic response and is therefore inappropriate. "Did you let your doctor know that you stopped taking the medication?" may be an appropriate question at some point during the conversation, but it is not the most appropriate initial question. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that" demeans the client.

A client who recently underwent coronary artery bypass graft surgery comes to the health care provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

"Tell me more about what you're feeling." Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will take time, but, I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client's feelings.

A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate?

"Tell me more about your concerns regarding the tube feedings." Rationale: A client often has fears about leaving the secure environment of the healthcare facility, where he or she is cared for. This client fears that he will not be able to care for himself at home by administering himself the tube feedings. An open statement such as "Tell me more about..." often elicits valuable information about the client and the client's concerns. The remaining nursing responses are incorrect because they are nontherapeutic statements that do not address the client's expressed concern.

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?

"The placenta maintains the body temperature of my baby."

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?

"The placenta maintains the body temperature of my baby." Rationale: Many of the immunoglobulin G (IgG) class of antibodies are passed from mother to fetus through the placenta. Glucose, fatty acids, vitamins, and electrolytes pass readily across the placenta; glucose is the major source of energy for fetal growth and metabolic activities. The placenta provides an exchange of nutrients and waste products between the mother and fetus. Oxygen and carbon dioxide pass through the placental membrane by way of simple diffusion. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus.

A client diagnosed with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation?

"Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"

A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation?

"Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"

The nurse identifies which client is at risk to develop metabolic acidosis? Select all that apply 1. (1.) A client diagnosed with type 1 diabetes mellitus. 2. (2.) A client diagnosed with salicylate toxicity. 3. (3.) A client diagnosed with bilateral bacterial pneumonia. 4. (4.) A client diagnosed with acute renal failure. 5. (5.) A client diagnosed with continuous nasogastric drainage. 6. (6.) A client diagnosed with severe diarrhea.

(1.) CORRECT - At risk for diabetic ketoacidosis (2.) CORRECT - Acidic medication (3.) At risk for respiratory acidosis (4.) CORRECT - Kidneys not able to excrete acids or absorb bases (5.) At risk for metabolic alkalosis; lose acids (6.) CORRECT - Lose base in diarrhea

The nurse presents a class on herbal medications at a community health care seminar. Which statement should be included in the class? Select all that apply 1. (1.) The potency of herbal preparations varies between manufacturers. 2. (2.) The FDA tests and regulates herbal preparations. 3. (3.) Herbal preparations are classified as dietary supplements. 4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure. 5. (5.) Herbal preparations are used in the treatment of immune system dysfunction.

(1.) CORRECT - read labels carefully to determine the exact amount of herbs in the preparation (2.) herbal preparations are classified as dietary supplements; adverse reactions may be reported after use (3.) CORRECT - the FDA does not research or regulate herbal preparations because they are classified as dietary supplements (4.) CORRECT - read labels carefully to determine what the herbal preparation contains (5.) label should state that the herbal preparation will "decrease inflammation or support the immune system"; label cannot say that the preparation "protects against cancer"

A client is prescribed prednisone and asks about possible adverse effects. The nurse teaches the client about which common adverse effects of prednisone? Select all that apply 1. (1.) Osteoporosis. 2. (2.) Decreased white count. 3. (3.) Low blood sugar. 4. (4.) Low serum potassium. 5. (5.) Retinal detachment. 6. (6.) Fluid retention

(1.) CORRECT-Glucocorticoids decrease bone density; calcium and vitamin D supplements or biphosphonates will decrease risk (2.) Glucocorticoids depress the immune response, but not the white cell count (3.) Glucorticoids cause hyperglycemia and glyxosuria (4.) CORRECT-Glucocorticoids cause hypokalemia and hypernatremia (5.) Glucocorticoids increase the risk of cataracts and glaucoma (6.) CORRECT-Glucocorticoids cause sodium and water retention

The nurse cares for a client with chronic renal failure who has an arteriovenous fistula in the left arm. Which of the following should be included in the care of the client? Select all that apply 1. (1.) Assess and compare blood pressure in both arms. 2. (2.) Auscultate for "whooshing" sound over the fistula. 3. (3.) Palpate for warmth and tenderness over the area of the fistula. 4. (4.) Instruct the client to avoid getting the left arm wet. 5. (5.) Instruct the client to sleep with the left arm in the dependent position. 6. (6.) Instruct the client to avoid carrying heavy objects with the left arm.

(1.) no constriction of the arm with the fistula; may damage fistula (2.) CORRECT - Bruit should be heard over the area of the fistula due to increased blood flow; if no bruit heard, notify healthcare provider (3.) CORRECT - Increased risk of infection in the fistula area; possible infection should be reported to healthcare provider (4.) fistula is internal; no risk of infection from exposure to water (5.) no weight should be placed on the extremity with the fistula (6.) CORRECT - increases the risk of fistula damage

A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast?

(Anatomy with the appearance and dimpled texture of an orange peel.) Rationale: Peau d'orange (French for "orange peel") is the term used to describe skin dimpling, resembling the skin of an orange, at the location of a breast mass. This change, along with increased vascularity, nipple retraction, or ulceration, may indicate advanced disease. Erythema, or reddening, of the breast indicates inflammation such as that resulting from cellulitis or a breast abscess. Paget's disease is a rare type of breast cancer that is manifested as a red, scaly nipple; discharge; crusting lasting more than a few weeks. In nipple retraction, the nipple is pointed or pulled in an abnormal direction. It is suggestive of malignancy.

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply.

*Beer *Yogurt *Pickled herring

A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply.

*Being honest, nonjudgmental, and empathetic *Assessing the immediate post-traumatic reaction *Encouraging the client to keep a journal focused on the trauma *Asking the client about the use of alcohol and drugs before and since the event

A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply.

*Drink copious amounts of fluid and void frequently *Avoid contact with any individual who has signs or symptoms of a cold

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply.

*Drooling *Excessive oral secretions

A nurse provides information to a client diagnosed with peripheral vascular disease about ways to limit the disease's progression. Which measures does the nurse tell the client to take? Select all that apply.

*Engaging in exercise such as walking on a daily basis *Washing the feet daily with a mild soap and drying them well

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply.

*Ensuring that direct pressure is applied to the external hemorrhage site *Ensuring a patent airway and supplying oxygen to the client as prescribed *Inserting an intravenous (IV) catheter and administering fluids as prescribed

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.

*Fatigue *Low-grade fever

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record?

*Fever *Vasculitis *Abdominal pain Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon, pleural effusions, joint inflammation, and myositis.

A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.

*Hunger *Weakness *Blurred vision

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply.

*Keep the volume of headphones at the lowest setting. *Avoid environmental conditions involving rapid changes in air pressure. *Clean the external ear and canal daily in the shower or while washing the hair.

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply.

*Keeping the room slightly darkened *Monitoring the client for changes in alertness or mental status *Restricting visits to close family members and significant others and keeping visits short

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which characteristic of the disorder does the nurse expect the client to exhibit? Select all that apply.

*Nausea *Eye pain *Vomiting *Headache

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.

*Skin tenting *Flat neck veins *Weak peripheral pulses

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply.

*Use a straw to drink. *Use caution when leaning forward or backward. *Do not drive, because full range of vision is impaired with the device.

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which recommendations does the nurse include on the poster? Select all that apply.

*Wear a hat, opaque clothing, and sunglasses when out in the sun. *Seek medical advice if you find a skin lesion. Rationale: Measures to prevent skin cancer include avoiding sun exposure between 10 a.m. and 4 p.m.; using sunscreen with a high SPF; wearing a hat, opaque clothing, and sunglasses when out in the sun; and examining the body every month for possibly cancerous or precancerous lesions. The client should also seek medical advice if any changes in a skin lesion are noted.

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply.

*Weight loss *Projectile vomiting *Distended upper abdomen

A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply.

-Drink copious amounts of fluid and void frequently -Avoid contact with any individual who has signs or symptoms of a cold

A nurse provides information to a client with peripheral vascular disease about ways to limit the disease's progression. Which of the following measures does the nurse tell the client to take? Select all that apply.

-Engaging in exercise such as walking on a daily basis -Washing the feet daily with a mild soap and drying them well

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply.

-Ensuring that direct pressure is applied to the external hemorrhage site -Ensuring a patent airway and supplying oxygen to the client as prescribed -Inserting an intravenous (IV) catheter and administering fluids as prescribed

A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided.

0.625mL

Which entry in the client's medical record provides the best documentation

0830- IV fluid rate increased to 100 ml/hour according to protocol.

A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer.

1

An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure.

1 Use an otoscope to ensure that the tympanic membrane is intact. 2 Warm tap water to body temperature. 3 Fill an irrigating syringe with warm water. 4 Insert the irrigating solution by directing the solution toward the wall of the ear canal. 5 Document the completion of the procedure and how the client tolerated it.

Haloperidol (Haldol) 5 mg IM every 4 hours PRN is prescribed for a client. Which observation requires an IMMEDIATE intervention by the nurse? 1. Patient reports dizziness; heart rate 58 beats per minute. 2. Patient has tongue protrusion and muscle rigidity. 3. Patient has a facial rash and periorbital edema. 4. Patient reports sensitivity to light and blurred vision.

1) Assessment: outcome a concern but not priority; can cause tachycardia 2) CORRECT-Assessment: outcome not expected and priority; extrapyramidal reactions usually dose-related; controlled by dose-reduction or antiparkinsonian medications (benztropine) 3) Assessment: outcome a concern but not priority; possible maculopapular rash 4) Assessment: outcome a concern but not priority; intolerance to light not seen; blurred vision not commonly seen

The nurse cares for a client 4 hours after admission to the hospital for treatment of an anterior wall myocardial infarction. The client suddenly reports difficulty breathing and appears very anxious. Which action should the nurse take FIRST? 1. Evaluate the client's cardiac rhythm. 2. Check for cyanosis of the hands and the toes. 3. Auscultate the client's posterior lung fields. 4. Listen to the apical heart rate.

1) Assessment: outcome desired but not priority; ABCs apply here 2) Assessment: outcome not desired; peripheral cyanosis is a late sign of hypoxemia 3) CORRECT-Assessment: outcome priority; anterior wall MI high risk for heart failure; assess client first and then equipment 4) Assessment: outcome desired but not priority; should be assessed, but ABCs apply here

The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take? 1. Check the client records to see if insulin was given prior to surgery. 2. Administer the 6 units of regular insulin subcutaneously. 3. Administer the insulin when oral fluids are tolerated. 4. Contact the healthcare provider.

1) Assessment: outcome desired but not priority; client needs insulin coverage now 2) CORRECT - Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs 3) Implementation: outcome not desired; needs insulin regardless of oral intake due to elevated blood glucose 4) Implementation: outcome not desired; no reason to contact healthcare provider; order is valid and appropriate for situation

A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? 1. Observe the color of the client's fingernail beds. 2. Assess the client's blood pressure in both arms. 3. Listen to the client's breath sounds. 4. Assess for intercostal retractions.

1) Assessment: outcome desired but not priority; cyanosis is a late sign of respiratory distress; central cyanosis will occur later than peripheral cyanosis 2) Assessment: outcome not desired; priority is to assess respiratory status; blood pressure may change due to decreased arterial oxygen levels; priority is to correct underlying problem 3) CORRECT - Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax 4) Assessment: outcome desired but not priority; late indication of respiratory distress; intercostal muscles are accessory muscles

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse? 1. 2+ pitting pretibial edema. 2. Sodium 128 mEq/L. 3. Weight gain of 2 kg in 24 hours. 4. Urine specific gravity 1.008.

1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water is retained; needs to be monitored 2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures 3) Asssessment: outcome desired but not priority; indicates fluid retention, not as important as hyponatremia; important to watch trends in weight 4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine will have high concentration and specific gravity due to excess ADH secretion

A woman is admitted to the hospital with a diagnosis of ovarian cancer. She has been treated with surgery and chemotherapy. The client states that she has no appetite and has lost 10 lbs in the last 4 weeks. Which statement, if made by the nurse, is MOST important? 1. "Have you noticed a decrease in your energy levels lately?" 2. "Do you notice any swelling of your hands and feet?" 3. "Describe your normal daily food intake." 4. "What are your favorite foods?"

1) Assessment: outcome desired but not priority; energy level decreased with malnutrition; is also adverse effect of chemotherapy 2) Assessment: outcome desired but not priority; protein deficiency may cause peripheral edema 3) Assessment: outcome desired but not priority; more important to provide nutrition 4) CORRECT-Assessment: outcome desired and priority; offer favorite foods to deal with the "here and now"

The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate (Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the MOST appropriate response by the nurse? 1. "How much does your child exercise on a daily basis?" 2. "Stop giving the Ritalin for several days to see if the appetite improves." 3. "At what time do you give your child the Ritalin medication?" 4. "What is your child's bedtime and when does he usually awaken?"

1) Assessment: outcome desired but not priority; methylphenidate has appetite suppressant effects 2) Implementation: outcome not desired; Ritalin should be tapered 3) CORRECT-Assessment: outcome desired and priority; long-acting Ritalin should be given after breakfast to decrease appetite-suppressant effects 4) Assessment: outcome not priority; more important to assess effect of medication on appetite

The nurse is called to the bathroom of a woman who delivered an 8 lb 4 oz male 12 hours ago. The nurse notes that there is blood running down the client's leg. Which statement, if made by the nurse, is BEST? 1. "Leave your perineal pad in the bathroom so I can evaluate the lochia." 2. "Why don't you go back to bed so you can rest?" 3. "Let me help you back to bed so I can check your fundus." 4. "Sit in this chair so I can check your blood pressure."

1) Assessment: outcome desired but not priority; more important to determine source of bleeding 2) Implementation: outcome not desired; need to determine source of bleeding; need to assist client 3) CORRECT- Assessment: outcome priority; determine if fundus is firm; bleeding may be caused by pooling of lochia in the vagina 4) Assessment: outcome desired but not priority; more important to determine the source of bleeding

The nurse cares for a client who returned 4 hours ago after a subtotal thyroidectomy procedure. The nurse notes that the client sounds more hoarse when speaking than he did 1 hour ago. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the gag and swallow reflex. 2. Instruct the client to chew small amounts of ice chips. 3. Notify the healthcare provider. 4. Instruct the client to cough and breathe deeply every 15 minutes.

1) Assessment: outcome desired but not priority; not best test for laryngeal damage 2) Implementation: outcome not desired; will not decrease hoarseness 3) CORRECT- Implementation: outcome priority and desired; possible laryngeal damage; further assessment and possible treatment indicated; do not assume that hoarseness is caused by endotracheal tube 4) Implementation: outcome not desired; may further damage operative site

A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is MOST appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.

1) Assessment: outcome desired but not priority; question stem tells you that assessment has been done; changes in pulse, color, sensation should be reported immediately to the healthcare provider 2) CORRECT - Implementation: outcome priority and desired; diminished pulses indicates change in circulation 3) Assessment: outcome desired but not priority; should report changes in circulation 4) Assessment: outcome not desired; symptoms suggest changes in circulation to extremity; more important to report change in distal circulation

The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse? 1. "My wife looks at the pin sites every day." 2. "I like to bathe in the tub." 3. "I drove to the library yesterday." 4. "I drink with a straw."

1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and infection 2) Implementation: outcome desired; showers increase risk of infection at pin sites 3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others 4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck

Based on the nurse's knowledge of the goal of diuretic therapy for a client with heart failure, which assessment BEST indicates that the client's condition is improving? 1. The client's weight has decreased 2 pounds. 2. The client's systolic blood pressure has decreased. 3. The client has fewer crackles heard during auscultation. 4. The client's urinary output has increased.

1) Assessment: outcome expected but not priority; could be due to changes in appetite, no time frame given in question 2) Assessment: outcome expected but not priority; could be due to other causes such as change in position 3) CORRECT- Assessment: outcome priority; reason for diuretics; diuretic reduces alveolar edema and pulmonary venous pressure 4) Assessment: outcome expected but not priority; will increase due to diuretic but may not change heart failure

The home care nurse visits a client diagnosed with Parkinson's disease. The nurse is MOST concerned if which of the following is observed? 1. The client has soft, monotonous speech. 2. The client is drooling. 3. The client rolls the left thumb against the fingers. 4. The client ambulates with a stooped posture.

1) Assessment: outcome expected, hypotonia; speech may be hard to understand 2) CORRECT-Assessment: outcome not expected; at risk for aspiration due to difficulty swallowing and the accumulation of saliva 3) Assessment: outcome expected, present at rest; may disappear with purposeful movement 4) Assessment: outcome expected, teach postural exercises to minimize this effect

The nurse cares for a client with Addison's disease who is taking 20 mg hydrocortisone (Cortef) daily. Which statement by the client requires an intervention by the nurse? 1. "I will need to have my blood sugar levels checked while on this medication." 2. "I may have episodes of low blood pressure while taking this medication." 3. "I need to weigh myself twice a week and keep a record of my weight." 4. "I should notify my health care provider if I am running a fever."

1) Assessment: outcome expected; glucocorticoids can increase serum glucose levels 2) CORRECT- Assessment: outcome not expected; hypertension due to sodium and water retention expected 3) Assessment: outcome expected; weight gain due to sodium and water retention expected 4) Implementation: outcome desired; glucocorticoids have immunosuppressant effect; client at high risk for infection

The nurse reviews health assessments completed by student nurses. Which assessment warrants further investigation? 1. An 11-year-old female who states that she has had 3 periods in the past 6 months. 2. A 13-year-old male with intermittent voice changes. 3. A 14-year-old male with bilateral breast enlargement. 4. A 15-year-old female with bilateral breast buds.

1) Assessment: outcome expected; irregular menstrual periods common during the first year or two after menarche 2) Assessment: outcome expected; age-appropriate and common 3) Assessment: outcome expected; temporary, age-appropriate phenomenon 4) CORRECT-Assessment: outcome not expected; one of the earliest changes of puberty; occurs from age 9-13

A child is admitted to the hospital with a diagnosis of status asthmaticus. The nurse is MOST concerned if which of the following is observed? 1. SaO2 91%. 2. Expiratory wheezing. 3. Intercostal retractions. 4. Arterial pH 7.25.

1) Assessment: outcome expected; minimal acceptable level 2) Assessment: outcome expected; continuous high-pitched musical sound; expected with asthma 3) Assessment: outcome expected; usually present with severe asthma 4) CORRECT- Assessment: outcome not expected; indicates severe respiratory acidosis, accumulation of CO2 is danger sign of impending respiratory failure and cardiac arrest

The nurse assesses the fetal monitor of a client in labor. Which fetal heart rate pattern requires an intervention by the nurse? 1. A baseline rate of 140-150 between contractions with moderate variability. 2. Consistent heart rate accelerations that coincide with fetal movements. 3. A heart rate that slows following the peak of the contraction and returns to baseline after the contraction ends. 4. Gradual slowing of the heart rate that begins with the onset of the contraction and returns quickly to the baseline.

1) Assessment: outcome expected; normal 2) Assessment: outcome expected; reassuring sign of fetal well-being 3) CORRECT-Assessment: outcome not expected; late deceleration; indicates fetal distress and uteroplacental insufficiency; treatment-position on left side, give O2, IVs, notify healthcare provider 4) Assessment: outcome expected; early deceleration; good fetal outcome

The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which of the following was observed? 1. A 3-month-old infant's back is rounded. 2. A 4-year-old has a blood pressure of 90/60. 3. A 5-year-old has a pulse of 88. 4. The hem of the skirt on a 10-year-old is longer on one side than the other.

1) Assessment: outcome expected; normal finding 2) Assessment: outcome expected; normal finding 3) Assessment: outcome expected; normal finding 4) CORRECT-Assessment: outcome not expected; symptom of scoliosis

The nurse supervises care of clients on a postoperative surgical unit. Which of the following requires an immediate intervention by the nurse? 1. The nursing assistive personnel (NAP) obtains vital signs on a client who had a bowel resection 24 hours ago. 2. The NAP assists a client who had an above-the-knee amputation apply an elastic bandage to the residual limb. 3. The NAP assists a client who had a stroke 3 days ago with feeding. 4. The NAP assists a client who had a laparoscopic cholecystectomy 6 hours ago ambulate.

1) Assessment: outcome expected; within NAP scope of practice; principles of delegation should be followed 2) Implementation: outcome desired; within NAP scope of practice 3) CORRECT-Implementation: outcome not desired; client requires assessment and evaluation; may have problems with gag and swallow reflex 4) Implementation: outcome desired; within NAP scope of practice; stable client; principles of delegation should be followed

The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if which of the by which observation? 1. The respiratory rate is 40 per minute with short periods of apnea. 2. The heart rate is 140 beats per minute with variation during sleeping and waking states. 3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows. 4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.

1) Assessment: outcome not a problem; 30-60 breaths/min with periods of apnea; normal 2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake 3) Assessment: outcome not a problem; startle reflex; normal until 4 months 4) CORRECT - Assessment: outcome not expected and is a problem; Babinski reflex; in newborn, should see dorsiflexion of big toe

The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a renal computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned if the client makes which statement? 1. "My blood sugar was 124 mg/dL this morning." 2. "I drank a glass of water at midnight." 3. "Sometimes I get dizzy when I first get out of bed." 4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."

1) Assessment: outcome not desired but not priority; further assessment needed 2) Implementation: outcome not a problem; NPO for 8 hours prior to scan 3) Assessment: outcome not desired but not priority; possible orthostatic hypotension; further assessment needed 4) Correct - Implementation: outcome not desired and priority; metformin should be held for 48 hours prior to tomography with contrast media; risk lactic acidosis with potential renal damage

The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and heart failure. Which action is MOST important for the nurse to take? 1. Check the client's blood pressure and heart rate immediately after ambulation. 2. Instruct the client to use a walker at all times during ambulation. 3. Encourage the client to walk with the feet as close together as possible. 4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.

1) Assessment: outcome not desired; blood pressure and heart rate should be assessed prior to ambulation; more important to assess for shortness of breath and activity tolerance 2) Implementation: outcome not desired; avoid soft-soled shoes; remove barriers; orthostatic precautions are priority; no indication in the question that a walker is needed 3) Implementation: outcome not desired; should have wide-based gait to distribute center of gravity; may be unsafe ambulation 4) CORRECT-Implementation: outcome desired and priority; elderly have decreased cerebral perfusion; antihypertensives and medications used to treat heart failure cause vasodilation

The nurse cares for a client in active labor. The client's membranes rupture spontaneously at 6 centimeters of dilation. Which action actions should the nurse take FIRST? 1. Check the fetal monitor. 2. Place the client on her right side. 3. Auscultate fetal heart rate. 4. Check the client's heart rate and blood pressure.

1) Assessment: outcome not desired; check client, not equipment; fetal monitor may give incorrect information 2) Implementation: outcome not desired; position on left side if needed to prevent pressure on vena cava; no information in question indicates fetal hypoxia 3) CORRECT-Assessment: outcome priority; check for possible prolapsed cord; recheck in 10 minutes; fetal assessment is priority during labor 4) Assessment: outcome not priority; provides no information about baby

The home care nurse is visiting a client terminally ill with pancreatic cancer who wishes to die at home. Which question, if asked by the nurse, is MOST appropriate? 1. "Are you sure you want to die at home?" 2. "Where will you put the hospital bed?" 3. "Would you like your minister to visit you?" 4. "Who will take care of you?"

1) Assessment: outcome not desired; psychosocial, yes-no question, non-therapeutic 2) Assessment: outcome desired but not priority; important to obtain the needed equipment, but is very specific 3) Assessment: outcome not priority; passing the buck, yes-no question, non-therapeutic 4) CORRECT- Assessment: outcome desired and priority; physical need, meet basic needs first before psychosocial

The nurse is caring for an elderly client receiving total parenteral nutrition (TPN) due to malnutrition. Which observation, if made by the nurse, indicates that the client is improving? 1. The client gains 8 lbs in one week. 2. The client's edema decreases. 3. The client's hemoglobin increases. 4. The client's output is greater than the intake.

1) Assessment: outcome not expected; indicates fluid retention 2) CORRECT- Assessment: outcome expected; edema is manifestation of malnutrition; decreased serum protein levels cause fluid to move into interstitial space 3) Assessment: outcome not expected; hemoglobin may increase with increased iron levels 4) Assessment: outcome not expected; TPN can cause hyperosmolar diuresis due to hyperglycemia, complication of TPN

The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds? 1. Continuous, high-pitched musical sounds heard on expiration. 2. Soft, high-pitched interrupted sounds heard on inspiration. 3. Deep, low-pitched rumbling sounds are heard mainly on expiration. 4. Harsh, grating sounds heard best during inspiration.

1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles 2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid in the alveoli 3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom 4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or pericarditis

The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?"

1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment 2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching 3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen consumption; increased risk of angina and myocardial infarction 4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work

The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain.

1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated 2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors 3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first 4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation

A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. 4. Ask the client if he knows today's date.

1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose 2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and breathing 4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority

An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a medication-error form since "no harm was done." Which statement, if made by the nurse, is BEST? 1. "What do you mean, "no harm was done"? 2. "A medication-error form must be completed whenever the wrong preparation of a medication is given." 3. "I will call the health care provider and ask what should be done to deal with this error." 4. "It is not necessary to complete an incident report with over-the-counter medications."

1) Assessment: outcome not priority; assessment of client must be done by nurse; question is not necessary 2) CORRECT-Implementation: outcome desired; contains full description of situation, error committed, condition of client, remedial steps taken; medication error form must be completed for all variances 3) Implementation: outcome not desired; it is a nursing responsibility; health care provider should be informed 4) Implementation: outcome not desired; always complete form for any medication error

A news reporter and camera person arrive on the nursing unit to videotape an interview of a client. When the nurse refuses their request, the reporter references his First Amendment rights. Which statement, if made by the nurse, is MOST appropriate? 1. "Why do you want to talk with the client?" 2. "I'll ask the client if he is ready to speak with you." 3. "I will need to call the nurse manager about your request." 4. "Does the client know that you are coming?"

1) Assessment: outcome not priority; don't ask "why" questions on the NCLEX-RN®; "why" questions are considered to be confrontational 2) Implementation: outcome not desired; confirms client presence; breaches confidentiality; report to nursing supervisor 3) CORRECT- Follows the chain of command within the facility. 4) Verified the client's admission, violates client's confidentiality.

The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of sweating and has a flushed face and chest. Which action should the nurse take FIRST? 1. Perform a digital rectal examination. 2. Check the color and temperature of the extremities. 3. Place the client in high-Fowler's position. 4. Administer hydralazine (Apresoline) 20 mg intravenously.

1) Assessment: outcome not priority; immediate action to decrease blood pressure is priority; rectal stimulation may increase autonomic dysreflexia 2) Assessment: outcome not priority; immediate need is to reduce blood pressure and prevent hemorrhage 3) CORRECT-Implementation: outcome desired; immediate effect; decrease venous return to heart, decrease stroke volume, and decrease in blood pressure 4) Implementation: outcome not desired as initial action; causes vasodilation; more immediate effect with position change; if cause of autonomic dysreflexia removed, sudden drop in blood pressure could occur

A 60-year-old client comes to the outclient clinic to receive the influenza vaccine. Which of the following questions, if asked by the nurse, is BEST? 1. "Have you had the flu in the past month?" 2. "Do you have any food allergies?" 3. "Has anyone in your family been sick?" 4. "Are you allergic to any medication?"

1) Assessment: outcome not priority; immunization deferred in presence of acute respiratory disease or other acute infection 2) CORRECT-Assessment: outcome priority; allergy to eggs is a contraindication to receiving flu vaccine 3) Assessment: outcome not priority; immunization deferred only if client has active infection 4) Assessment: outcome not priority; medication allergy not pertinent

The nurse teaches a wellness class to a group of women. The nurse knows that which of the following clients is MOST at risk for developing cervical cancer? 1. A woman who began menstruating at age 9. 2. A woman who used oral contraceptives for 8 years. 3. A woman diagnosed with endometriosis at age 20. 4. A woman who has had approximately 10 sexual partners.

1) Assessment: outcome not priority; increases risk of breast cancer 2) Assessment: outcome not priority; increases risk of estrogen-dependent cancers 3) Assessment: outcome not priority; not related to cervical cancer 4) CORRECT-Assessment: outcome priority; multiple sexual partners increases risk of cervical cancer

The nurse cares for the client diagnosed with schizophrenia. Which question is MOST important for the nurse to ask the client's spouse? 1. "Have you noticed loud talking and excessive restlessness lately?" 2. "Has your spouse seemed withdrawn and less responsive to you during the last few weeks?" 3. "How would you describe your spouse's daily consumption of alcohol?" 4. "Does your spouse appear to have lost weight recently?"

1) Assessment: outcome not priority; manic client (bipolar disorder); symptoms include inappropriate dress, excessive talking, lack of inhibition, inability to stop moving, disorientation 2) CORRECT - Assessment: outcome priority; may withdraw from previous relationships or regress to previous behavior levels 3) Assessment: outcome not priority; no data to support relationship 4) Assessment: outcome not priority; secondary to withdrawn behavior; common with other psychiatric problems

The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monitor the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).

1) Assessment: outcome not priority; may cause anemia, but not usually seen 2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance 3) Assessment: outcome not priority; will be increased in inflammation and rheumatoid arthritis 4) Assessment: outcome not priority; will be increased with any inflammatory process

The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed? 1. The client has a forceful cough during repositioning. 2. The client tries to chew on the oral airway.. 3. The client tries to push the airway out with his tongue. 4. The client is able to swallow.

1) Assessment: outcome not priority; may cough due to irritation of the airway; does not reflect client responsiveness 2) CORRECT - Assessment: outcome priority; client is alert and able to maintain his own airway 3) Assessment: outcome not priority; client needs to be responsive before airway is removed; may be a reflexive action 4) Assessment: outcome not priority; client will be able to swallow before he is responsive

The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. The nurse notes that the client appears to have difficulty understanding what is said. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Ask the client if cotton-tipped applicators are used for ear cleaning. 2. Perform the Weber hearing test. 3. Check the client's ear canals for cerumen. 4. Use facial expressions and speak in a high frequency tone of voice.

1) Assessment: outcome not priority; most common cause is cerumen in elderly 2) Assessment: outcome not priority; cerumen most likely cause 3) CORRECT- Assessment: outcome priority; physical, ear wax becomes drier in elderly; can block ear canal and cause decreased hearing 4) Implementation: outcome not priority; nonverbal cues useful when speaking to hearing-impaired; need low tones; high frequency tones are problem for elderly

A client is scheduled for transfer to another hospital. Which observation, if made by the nurse, would require an IMMEDIATE intervention? 1. Lactated Ringer's infusing IV into the client's left forearm is 400 mL behind schedule. 2. The client's nasogastric tube is draining a moderate amount of green liquid. 3. The client's blood pressure has changed from 140/80 to 150/88 in the last hour. 4. The client's SaO2 is 88%.

1) Assessment: outcome not priority; needs to be investigated 2) Assessment: outcome not priority; no indication of a problem 3) Assessment: outcome not priority; still the same range 4) CORRECT- Assessment: outcome priority; decreased oxygenation level; needs further assessment

A 56-year-old man is scheduled for an MRI (magnetic resonance imaging). His history indicates that he suffered an injury during the Vietnam War. Which question is MOST important for the nurse to ask the client? 1. Where was your injury? 2. When were you wounded? 3. Did your injury involve shrapnel? 4. Were you exposed to chemical warfare?

1) Assessment: outcome not priority; not significant for MRI 2) Assessment: outcome not priority; not significant for MRI 3) CORRECT- Assessment: outcome desired and priority; MRI contraindicated with metal prosthesis or implanted metal 4) Assessment: outcome not priority; defoliant used in war, not significant for MRI

The nurse prioritizes the needs of a client who has been raped. Which nursing action is MOST important? 1. Observe the client for withdrawn, tearful behavior. 2. Determine if the client sustained any injuries. 3. Obtain information about events which preceded the rape. 4. Accurately document the client's comments about the rape.

1) Assessment: outcome not priority; psychosocial assessment; eliminate; address physical needs first 2) CORRECT - Assessment: outcome priority; physical needs are highest priority 3) Assessment: outcome desired but not highest priority; address physical needs first 4) Implementation: outcome not highest priority; legal documentation is not the highest priority

A client calls the healthcare provider's office reporting a rash, intermittent fever, headache, fatigue, muscle pain, and stiff neck. It is MOST important for the nurse to ask which question? 1. "Have you ever felt this way before?" 2. "Have you noticed any swollen areas on your neck?" 3. "Have you recently noticed any flea bites?" 4. "Have you noticed any tick bites recently?"

1) Assessment: outcome not priority; question too general 2) Assessment: outcome not priority; enlarged lymph glands indicate an inflammatory response or neoplastic disorder 3) Assessment: outcome not priority; causes papular urticaria, not systemic symptoms 4) CORRECT-Assessment: outcome priority; symptoms of Lyme disease; causes localized and systemic symptoms

A client is admitted to the hospital with a diagnosis of chronic bronchitis. Which action should the nurse take FIRST? 1. Weigh the client. 2. Place cardiac telemetry leads. 3. Place pulse oximetry on finger. 4. Obtain a sputum specimen

1) Assessment: outcome not priority; right heart failure and weight gain seen with chronic bronchitis; priority is to assess oxygenation 2) Assessment: outcome not priority; dysrhythmias occur due to right heart failure; priority is oxygenation 3) CORRECT-Assessment: outcome desired; priority is to establish oxygenation status 4) Assessment: outcome not priority; common reason for worsening status is respiratory infection; more important to establish respiratory status first

The home care nurse performs a health screening at the local mall. The nurse knows that which of the following clients is at HIGHEST risk for developing a stroke? 1. A 32-year-old Caucasian female who has a history of type 1 diabetes mellitus and has used oral contraceptive for 8 years. 2. A 49-year-old Caucasian male who works as an account executive at an ad agency and has a cholesterol level of 250 mg/dL. 3. A 56-year-old African-American female who consumes 1 to 2 alcoholic beverages weekly and has smoked cigarettes for 30 years. 4. A 69-year-old African-American male who has a history of hypertension and is 30 pounds overweight.

1) Assessment: outcome not priority; risk factors include diabetes and oral contraceptive use 2) Assessment: outcome not priority; risk factors include high cholesterol; no demonstrated relationship between occupation and stroke 3) Assessment: not priority; risk factors include race and smoking; daily consumption of 2 or more alcoholic beverages a day increases risk of hypertension and stroke 4) CORRECT- Assessment: priority; risk factors include age, race, hypertension, and obesity

A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client, indicates to the nurse that the client is experiencing rejection? 1. The client complains of generalized muscle weakness. 2. The client complains of diffuse pain over the right abdomen. 3. The client gets up twice each night to void. 4. The client has lost 3 pounds.

1) Assessment: outcome not priority; seen with electrolyte imbalance, not rejection 2) CORRECT-Assessment: outcome priority and expected with kidney rejection; tenderness over kidney is sign of rejection 3) Assessment: outcome not expected; oliguria is seen with rejection due to failing kidney 4) Assessment: outcome not expected; edema and weight gain are seen with rejection

A client is brought to the clinic by the spouse. The client's lab results are Na+ 156 mEq/L, Cl- 100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the MOST appropriate action for the nurse to take? 1. Assess for muscle weakness and dysrhythmias. 2. Assess for confusion and tachycardia. 3. Check for peripheral edema and lung crackles. 4. Determine if muscular twitching and muscle weakness are present.

1) Assessment: outcome not priority; symptoms of hypokalemia 2) CORRECT-Assessment: outcome priority; elevated Na+ and elevated BUN, other values are normal; elevated Na+ and BUN seen with dehydration 3) Assessment: outcome not priority; symptoms of fluid volume overload 4) Assessment: outcome not priority; symptoms of hyponatremia; hypernatremia seen with dehydration

During a paracentesis, 1500 mL of fluid is removed from a client. Which action should the nurse take IMMEDIATELY following the procedure? 1. Measure the client's abdominal girth. 2. Weigh the client. 3. Assess the client's level of pain. 4. Check the client's blood pressure.

1) Assessment: outcome not priority; will decrease in size 2) Assessment: outcome not priority; will lose weight 3) Assessment: outcome not priority; not most important 4) CORRECT- Assessment: outcome priority; complication of procedure is hypotension (hypovolemic shock due to fluid shift); also check for tachycardia, oliguria, pallor

The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? 1. "I have been sleeping 6 hours at night." 2. "I have lost 2 lbs in the past week." 3. "Lately, I have trouble watching television." 4. "I have much less muscle tension now."

1) CORRECT - Assessment: outcome desired; clients with depression may have increased or decreased sleep time 2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression 3) Assessment: outcome not desired; lack of concentration is sign of depression 4) Assessment: outcome not desired; is a sign of anxiety

The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which laboratory value demonstrates an improvement in the client's condition? 1. Specific gravity of urine 1.020 and hematocrit 42%. 2. Specific gravity of urine 1.039 and hematocrit 50%. 3. Specific gravity of urine 1.010 and hematocrit 52%. 4. Specific gravity of urine 1.030 and hematocrit 35%.

1) CORRECT - Assessment: outcome expected; normal specific gravity of urine, normal hematocrit; specific gravity and hematocrit increase with dehydration 2) Assessment: outcome not expected; increased specific gravity of urine, increased hematocrit; suggests ongoing fluid volume deficit 3) Assessment: outcome not expected; decreased specific gravity of urine, increased hematocrit; does not indicate improvement 4) Assessment: outcome not expected; increased specific gravity of urine, decreased hematocrit; does not indicate improvement

A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours. 4. Blood pressure of 100/82.

1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated 2) Assessment: outcome not priority; indicates that blood is hemoconcentrated 3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours 4) Assessment: outcome not priority; normal BP is 120/80

The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take FIRST? 1. "Show me how you check a capillary glucose level." 2. "How many of these glucose checks have you done in the past?" 3. "Would you like for me to go with you when you do the glucose test?" 4. "Was this procedure covered during your nursing assistive personnel class?"

1) CORRECT - Assessment: outcome priority; must evaluate competency of the UAP; nurse is accountable for UAP's actions during delegation process 2) Assessment: outcome not priority; number of procedures done is not as important as demonstrated competency 3) Assessment: outcome not priority; nurse should be able to delegate procedure if UAP is competent 4) Assessment: outcome not priority; obtaining a capillary glucose sample is within UAP scope of practice

The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? 1. A 38-year-old client with a diagnosis of systemic lupus erythematosus. 2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer. 3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg. 4. A 74-year-old client who has received intravenous antibiotics for 7 days.

1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious 2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased risk for infection 3) Implementation: outcome not desired; generalized skin infection of deeper connective tissue; usually caused by Streptococcus or Staphylococcus; increased risk for infection 4) Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy are at risk for Clostridium difficile infection; highly contagious; increased risk for infection

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.

1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement 2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection 3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures 4) Implementation: outcome not desired; increases the risk of trauma to lower airways

The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1. Inform the health care provider that the client is menstruating. 2. Send the urine collected prior to the onset of the client's menstruation to the lab. 3. Insert an indwelling bladder catheter during the remainder of the collection period. 4. Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period.

1) CORRECT - Implementation: outcome desired; menstruation may last several days to a week; protein and red cells may alter the results of the urinalysis 2) Implementation: outcome not desired; all urine must be collected for accuracy 3) Implementation: outcome not desired; invasive procedure should be avoided if possible 4) Implementation: outcome not desired; would change the results of the 24-hour urine sample; all urine must be collected for accuracy

A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a monogamous relationship. Which statement by the nurse is BEST? 1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the vasectomy." 2. "No other form of birth control is necessary for you or your wife at this time." 3. "You do not need to wear a condom when having sexual intercourse for the next few weeks, but your wife should use spermicidal jelly." 4. "Always wear a condom when having sexual intercourse because not all vasectomies are successful."

1) CORRECT - Implementation: outcome desired; sperm count decreased after the vasectomy; some sperm may remain in the vas deferens 2) Implementation: outcome not desired; sperm stored in vas deferens may be ejaculated for several weeks after the vasectomy 3) Implementation: outcome not desired; not effective enough 4) Implementation: outcome not desired; considered successful after 2 negative sperm counts

A 12-year-old diagnosed boy with a fractured right femur is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which client statement? 1. "I will experience more muscle spasms and pain while my leg is in traction." 2. "I can lift my body up while I grab the overhead trapeze and bend my left leg." 3. "The health care provider told me it is okay to move the head of my bed up and down by myself." 4. "I need to put the phone where I can reach for it without moving onto my side."

1) CORRECT - Implementation: outcome not desired; muscle spasm should decrease with traction; if muscle spasm pain increases, the amount of traction weight should be assessed 2) Implementation: outcome desired; vertical movement is allowed as long as line of pull is maintained 3) Implementation: outcome desired; balanced suspension traction not affected by movement of bed; not affected by client movement unless line of pull affected 4) Implementation: outcome desired; can move up and down only, moving side-to-side changes line of pull of traction

The nurse cares for a client 4 hours after admission to the neuroscience unit due to a closed-head injury. Which is the MOST important action for the nurse to take? 1. Assess pupil shape and reactivity. 2. Take the client's rectal temperature. 3. Assess blood pressure and apical heart rate. 4. Observe the client's oxygen saturation level.

1) CORRECT- Assessment: outcome desired and priority; change in pupil size, shape, or reactivity is an early sign of increased intracranial pressure; report to healthcare provider immediately 2) Assessment: outcome not priority; increased temperature late sign of increased intracranial pressure; temperature elevation may be due to other injuries 3) Assessment: outcome not priority; changes in vital signs are late sign of increased intracranial pressure 4) Assessment: outcome desired but not priority; increased carbon dioxide level will increase intracranial pressure

The husband of a woman at 39 weeks gestation calls the clinic nurse and states, "My wife's water just broke, and I think she's going to have the baby!" Which statement, if made by the nurse, is BEST? 1. "Look at your wife's vaginal area and tell me what you see." 2. "Time the contractions for 5 minutes." 3. "Tell your wife to pant between contractions." 4. "I will instruct you about how to deliver the baby."

1) CORRECT- Assessment: outcome desired and priority; determine if presenting part is crowning 2) Assessment: outcome desired but not priority; need to determine stage of labor first 3) Implementation: outcome not desired; need to determine stage of labor first 4) Implementation: outcome not desired; need to assess first

A client returns to the unit following a thyroidectomy. Which assessment finding requires an intervention by the nurse? 1. The client makes noises when breathing. 2. The client reports pain at the surgical site. 3. The client asks for liquids to drink. 4. The client is sleepy from anesthesia.

1) CORRECT- Assessment: outcome not expected and priority; sign of tracheal compression caused by hemorrhage or edema 2) Assessment: outcome expected; use analgesics, semi-Fowler's position 3) Assessment: outcome expected; NPO status prior to surgery 4) Assessment: outcome expected

The home care nurse visits a client who had a traditional cholecystectomy 10 days ago. The client returned to the healthcare provider to have the T-tube removed 2 days ago. It is MOST important for the nurse to take which action? 1. Observe the color of the client's urine and stool. 2. Ask the client to describe the quality and quantity of pain she is experiencing. 3. Instruct the client to avoid fatty foods for 6 weeks. 4. Listen to bowel sounds.

1) CORRECT- Assessment: outcome priority; clay-colored stools and dark urine indicate that bile is draining into liver 2) Assessment: outcome not priority; psychosocial, not as important as assessing color of urine and stool 3) Implementation: outcome desired but not priority; should eat balanced diet and avoid high-fat foods 4) Assessment: outcome not priority; more important to assess urine and stools

A client with an 8-year history of ulcerative colitis is admitted to the hospital with severe abdominal cramping and diarrhea. The client has experienced 18 to 20 stools a day for the last 4 days. The nurse is MOST concerned by which finding? 1. The client's diastolic blood pressure decreases 20 mm when the client rises to a standing position. 2. The client's urinary specific gravity is 1.020. 3. The client has lost 3 pounds since her last admission. 4. The client appears pale and thin.

1) CORRECT- Assessment: outcome priority; indicates fluid volume deficit, check blood pressure supine, sitting and standing; other symptoms include concentrated urine and weak, rapid pulse 2) Assessment: outcome not priority; normal 1.010-1.030 3) Assessment: outcome not priority; don't know when client was last hospitalized 4) Assessment: outcome not priority; more concerned about fluid volume deficit

A 22-year-old woman at term comes to the hospital in labor. Two hours after admission, the client remains 4 centimeters dilated, and her contractions are weak. The healthcare provider orders oxytocin (Pitocin). Which finding would require an intervention by the nurse? 1. Contractions every 2 minutes, lasting 90 seconds. 2. Contractions every 3-4 minutes, lasting 60 seconds. 3. Fetal heart rate of 110 beats per minute at the peak of a contraction. 4. Fetal heart rate of 158 bpm at the end of a contraction.

1) CORRECT- Assessment: outcome priority; only 30 seconds between contractions; hypertonic labor pattern; results in fetal distress 2) Assessment: outcome not priority; normal frequency and duration 3) Assessment: outcome not priority; reassuring fetal heart tones 4) Assessment: outcome not priority; reassuring fetal heart tone

A 50-year-old woman with a history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. It would be MOST important for the nurse to obtain the answer to which question? 1. "When did you have your last drink?" 2. "How much alcohol have you consumed?" 3. "Have you ever used drinking in the morning to get rid of a hangover?" 4. "How many drinks do you need before you feel high?"

1) CORRECT- Assessment: outcome priority; withdrawal 5-35 hours after last drink; grand mal seizures 48 hours after; delirium tremens 72-96 hours after; client at high risk for seizures 2) Assessment: outcome not priority; may be included as part of the assessment 3) Assessment: outcome not priority; may be included as part of the assessment 4) Assessment: outcome not the priority; may be included but timing is more important to anticipate withdrawal.

The nurse is caring for clients in the pediatric clinic. Which of the following clients should the nurse see FIRST? 1. An 8-month-old infant who had 6 watery stools in the past 8 hours. 2. A 13-month-old infant who received the MMR immunization 8 days ago and has a temperature of 101° F (38.3° C). 3. A 2-year-old child who has swelling, pain, and tenderness of the upper arm after falling off a chair. 4. An 8-year-old discharged from the hospital 2 days ago for asthma.

1) CORRECT- Diarrhea causes dehydration and electrolyte imbalances; needs to be evaluated 2) Normal reaction to MMR; stable 3) Needs continued observation; not the priority client 4) Requires follow-up; stable at this time

The nurse teaches a client about foods and beverages that may be consumed on a low- sodium diet. Which beverage, if selected by the client, indicates an understanding of the instructions? 1. Lemonade. 2. Skim milk. 3. Ginger ale. 4. Tomato juice.

1) CORRECT- Implementation: outcome desired; 1 cup = 2 mg Na+ 2) Implementation: outcome not desired; 1 cup = 125 mg; high Na+ in milk products 3) Implementation: outcome not desired; 1 cup = 60 mg; high Na+ in carbonated beverages 4) Implementation: outcome not desired; 1 cup = 500 mg; extremely high Na+

Heparin 5,000 units subcutaneously is ordered every 12 hours for a client. The result of the client's most recent PTT is 55 seconds. Which action by the nurse is MOST appropriate? 1. Document the result and administer the heparin. 2. Withhold the heparin. 3. Notify the healthcare provider. 4. Have the test repeated.

1) CORRECT- Implementation: outcome desired; PTT lower limit of normal 20 - 25 seconds, upper limit of normal 32 to 39 seconds, therapeutic range 1.5 to 2 times normal, 5 seconds is within therapeutic range 2) Implementation: outcome medication should be given; PTT is in therapeutic range 3) Implementation: outcome not desired; unnecessary 4) Implementation: outcome not desired; unnecessary

The nurse teaches a client with a spinal cord injury how to perform self-catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? 1. "I will keep the catheter in a plastic bag." 2. "I will catheterize myself every 2 hours." 3. "I will wear sterile gloves." 4. "I will wash the perineum with alcohol prior to catheterizing myself."

1) CORRECT- Implementation: outcome desired; after use, catheter is soaked in solution of Betadine, bleach, or hydrogen peroxide, then dried and stored in a towel or bag; clean procedure in the home 2) Implementation: outcome not desired; done every 6-8 hours 3) Implementation: outcome not desired; clean procedure in the home, less risk of contamination 4) Implementation: outcome not desired; wash with soap and water

The health care provider (HCP) provider orders hydralazine 25 mg IM on call for a client before surgery. The LPN/LVN administers hydroxyzine 25 mg IM to the client. Which of the following is the MOST appropriate action for the nurse to take? 1. Document "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12." 2. Document "Hydroxyzine 25 mg given; hydralazine 25 mg ordered; HCP notified; vital signs stable." 3. Document "Hydroxyzine 25 mg mistakenly given; hydralazine 25 mg ordered." 4. Document "Hydroxyzine 25 mg given; incident report completed."

1) CORRECT- Implementation: outcome desired; objective; indicates nurse has monitored client 2) Implementation: outcome not desired; not best; contains judgment 3) Implementation: outcome not desired; incomplete; subjective 4) Implementation: outcome not desired; incident report not part of legal record

A woman is admitted to the hospital complaining of diarrhea and vomiting for 3 days. The blood pressure is 90/60, apical heart rate 96, and respiratory rate 22 with shallow respirations. Laboratory results include Na+ 147 mEq/L, K+ 5.6 mEq/L, hematocrit 52%, hemoglobin 14 g/dL. The client is receiving 5% dextrose in 0.45% normal saline with K+ 20 mEq at 125 mL/hr. Prior to calling the healthcare provider, it is MOST important for the nurse to take which of these actions? 1. Change IV fluids to 5% dextrose in 0.45% normal saline. 2. Increase IV flow rate to 150 mL/hour. 3. Check the hourly urine output. 4. Observe the client for muscle weakness.

1) CORRECT- Implementation: outcome desired; potassium removed due to hyperkalemia; hypotonic solution used to correct dehydration 2) Implementation: outcome not desired; will increase serum potassium 3) Assessment: outcome not priority; client is dehydrated; intervention required 4) Assessment: outcome not priority; lab values indicate hyperkalemia

In preparation for a total laryngectomy, the nurse teaches a client how to support his neck after surgery. Which of the following demonstrations by the client indicates to the nurse that teaching is successful? 1. The client raises the elbows and places the hands behind the neck. 2. The client places one hand on the forehead and the other hand on the back of the head. 3. The client covers the ears with both hands and presses firmly. 4. The client grasps the chin with one hand and places the other hand on the forehead.

1) CORRECT- Implementation: outcome desired; prevents stress on suture line; supports head; use folded towel when mobile 2) Implementation: outcome not desired; no support for neck 3) Implementation: outcome not desired; no support for neck 4) Implementation: outcome not desired

The nurse plans care for a 42-year-old man receiving disulfiram (Antabuse). Which of the following statements requires an IMMEDIATE intervention by the nurse? 1. "This medication will prevent me from drinking alcohol." 2. "I should not take cough syrup preparations while taking Antabuse." 3. "If I discontinue the Antabuse, I should not consume alcohol for 2 weeks." 4. "Even small amounts of alcohol may cause nausea, vomiting, and headache."

1) CORRECT- Implementation: outcome not desired; does not prevent drinking, unpleasant reaction may decrease frequency of drinking 2) Implementation: outcome desired; must avoid all forms of alcohol, sauces, cough syrups, external, shaving lotions, liniments, back rub preparations 3) Implementation: outcome desired; effects continue for 2 weeks 4) Implementation: outcome desired; amounts as small as 7 ounces can cause reaction

Levodopa (L-Dopa) is prescribed for a 61-year-old woman. Which statement, if made by the client to the nurse, would indicate that the client needs further instruction? 1. "While I take this medication, I should eat a high-protein diet." 2. "I should change positions slowly at first so I don't get dizzy." 3. "If I have muscle twitching, I should report it to my health care provider." 4. "I should check with my health care provider before taking any over-the-counter medications."

1) CORRECT- Implementation: outcome not desired; take with low-protein diet to decrease GI upset 2) Implementation: outcome desired; true; orthostatic hypotension is common with Parkinson's disease 3) Implementation: outcome desired; true; blepharospasms (twitching eyelid) are early signs of overdosage 4) Implementation: outcome desired; true; multivitamins can reverse actions, especially vitamin B6

The home care nurse makes an initial visit to an 80-year-old client. The client's daughter states that her mother has a history of colon cancer and has been restless and confused for about a week. It is MOST important for the nurse to obtain an answer to which question? 1. "What medication is your mother taking?" 2. "Is there a family history of diabetes?" 3. "Describe your mother's usual diet." 4. "Does your mother complain of difficulty urinating?"

1) CORRECT-Assessment: outcome desired and priority; confusion can be caused by drug toxicity and polypharmacy; decreased renal function may increase risk 2) Assessment: outcome desired but not priority; hypoglycemia may be a factor 3) Assessment: outcome desired but not priority; is a good open-ended question 4) Assessment: outcome desired but not priority; not most important; urinary tract infections cause acute confusion in elderly

A client contaminated with an unidentified hazardous material arrives by ambulance at a local hospital. Which action should the nurse take FIRST? 1. Determine the decontamination that occurred in the field. 2. Reassure the client that he will receive excellent care. 3. Identify the type of hazardous material. 4. Remove all the client's clothing.

1) CORRECT-Assessment: outcome desired; nurse needs to determine if the situation is a threat to the caregiver; important to prevent the spread of contamination; flushing with water dilutes or reduces the amount of hazardous material 2) Implementation: not a priority; attend to the physical needs of client and staff 3) Assessment: outcome not desired; will be done by other health professionals; more important to determine level of decontamination in field 4) Implementation: outcome desired but not a priority; will reduce 80 to 90% contamination; more important to determine if decontamination occurred to ensure safety of client and staff

The nurse observes a student nurse examine a client's chest. Which action requires an intervention by the nurse? 1. The student nurse auscultates heart sounds and then palpates for tactile fremitus. 2. The student nurse uses the diaphragm of the stethoscope to listen to heart sounds. 3. The student nurse places the stethoscope firmly against the skin surface. 4. The student nurse inspects the chest before performing palpation.

1) CORRECT-Assessment: outcome desired; order for physical assessment is inspection, palpation, percussion, and auscultation; tactile fremitus is vibration produced when client says "99" 2) Assessment: outcome desired; used to listen for high-pitched sounds such as vesicular breath sounds 3) Assessment: outcome desired; a tight seal increases accuracy 4) Assessment: outcome desired; the order for physical assessment is inspection, palpation, percussion, and auscultation

A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1. Check the patency of the catheter. 2. Assess residual urine volume using bladder ultrasonography. 3. Assess the amount of drainage in the urinary drainage bag. 4. Decrease the tension on the catheter.

1) CORRECT-Assessment: outcome priority; catheter may be blocked or client may be having bladder spasms 2) Assessment: outcome not priority; need to check patency of tubing first 3) Assessment: outcome not priority; more important to look for obstruction in tubing 4) Implementation: outcome not desired; decrease in traction against bladder neck could cause bleeding; is a healthcare provider order and should not be changed

On the third day after a thyroidectomy, the nurse notes that the client has developed tremors. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the client's calcium level. 2. Check the client's glucose level. 3. Check the client's potassium level. 4. Check the client's sodium level.

1) CORRECT-Assessment: outcome priority; parathyroid gland may be injured, causing hormone levels to decrease; causes decrease in blood calcium; early signs include tingling of fingers, toes, lips 2) Assessment: outcome desired but not priority; blood glucose below 50 mg/dL; symptoms include sweating, trembling, anxiety, hunger, weakness 3) Assessment: outcome desired but not priority; K+ below 3.5 mEq/L; symptoms include fatigue, vomiting, muscle weakness, dysrhythmias 4) Assessment: outcome desired but not priority; if Na+ below 135 mEq/L; symptoms include muscle cramps, lethargy, hemiparesis (paralysis of one side of body)

A woman with a diagnosis of Alzheimer's disease is admitted to the hospital for treatment of an upper respiratory tract infection. On admission, she is incontinent of urine. When assigning the client to a room on the nursing unit, which location would be BEST? 1. A semi-private room near the nurse's station. 2. A private room near the nurse's station. 3. A private room away from the nurse's station. 4. A semi-private room away from the nurse's station.

1) CORRECT-Implementation: outcome desired and priority; stimulation helps with orientation; allows for frequent assessment 2) Implementation: outcome not desired; meets safety needs but lacks environmental stimulation 3) Implementation: outcome not desired; client should be frequently assessed and needs stimulation 4) Implementation: outcome not desired; does provide environmental stimulation but client should be frequently assessed

The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if the family makes which statement? 1. "We wear a fresh pair of clean gloves with each diaper change." 2. "We are not allowing our other children to be in the same room with the baby." 3. The grandmother wears a mask when changing the baby's diaper. 4. The mother wears an apron when changing the baby's diaper.

1) CORRECT-Implementation: outcome desired; contact precautions; Clostridium difficile infection may develop after antibiotic treatment 2) Implementation: outcome not desired; unnecessary; should use stool and enteric precautions 3) Implementation: outcome not desired; mask unnecessary; used for airborne infection 4) Implementation: outcome not desired; need to use contact precautions, gown only if soiling likely

The nurse teaches a client who is lactose-intolerant about some alternative ways to maintain an adequate diet. The nurse will suggest the client include which food items in the diet? 1. Tofu and green leafy vegetables. 2. Beef and tomato salad. 3. Cottage cheese and yogurt. 4. Custard and mashed potatoes.

1) CORRECT-Implementation: outcome desired; good sources of calcium 2) Implementation: outcome not desired; contain no calcium 3) Implementation: outcome not desired; contain lactose 4) Implementation: outcome not desired; made with milk; contain lactose

The home care nurse is visiting an alert, oriented woman living with her daughter. The client is malnourished and has multiple bruises on her body, and the situation is reported to the appropriate authority. After counseling the client and daughter, the nurse notes the situation has not improved. The client decides to remain with her daughter. Which action, if taken by the nurse, is MOST appropriate? 1. Respect the client's decision to stay in her daughter's home. 2. Insist the client move in with her other child. 3. Begin guardianship procedures. 4. Place live-in help in the home.

1) CORRECT-Implementation: outcome desired; intervention not possible without consent of the senior if person is legally competent; further assessment needed to determine cause of bruises 2) Implementation: outcome not desired; legally competent senior can choose where to live and with whom 3) Implementation: outcome not desired; appropriate if senior is legally incompetent and in immediate danger 4) Implementation: outcome not desired; must have consent of client

The nurse assesses the IV site before administering vancomycin. The nurse notes that the area around the IV infusion site is pale and feels cool. Which INITIAL action will the nurse perform? 1. Remove the intravenous catheter and elevate the arm on 1 or 2 pillows. 2. Begin the vancomycin infusion and reassess the infusion site in 15 minutes. 3. Withhold the vancomycin infusion and notify the healthcare provider. 4. Apply warm, moist compresses to the infusion site for 30 minutes and then administer the medication.

1) CORRECT-Implementation: outcome desired; possible infiltration; high risk of tissue damage and thrombophlebitis during vancomycin administration 2) Implementation: outcome not desired; priority is to discontinue infusion and prevent harm to client 3) Implementation: outcome not desired; medication should be given; no need to notify healthcare provider 4) Implementation: outcome not desired; warmth indicated for thrombophlebitis, not infiltration

The nurse cares for a client 72 hours after a right-below-knee amputation. Which is the MOST important action for the nurse to take? 1. Lay the client prone for 25 minutes every 3-4 hours. 2. Dangle the client's residual limb over the side of the bed. 3. Abduct the client's residual limb by placing pillows between the legs. 4. Elevate the client's residual limb on a pillow.

1) CORRECT-Implementation: outcome desired; prevents hip flexion contracture 2) Implementation: outcome not desired; will increase edema 3) Implementation: outcome not desired; legs should be adducted to prevent flexion contractures 4) Implementation: outcome not desired; done for the first 24 hours; increases venous return; prevents edema; promotes comfort

A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client assignment is MOST appropriate for this nurse? 1. A 5-month-old infant after a cast application on the left extremity due to club foot. 2. A 4-year-old boy with right abdominal swelling and a decreased appetite. 3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C). 4. A 10-year-old girl with newly diagnosed type 1 diabetes.

1) CORRECT-Implementation: outcome desired; stable client with predictable outcome; serial casting used to correct congenital club foot 2) Implementation: outcome unstable client; needs assessment and evaluation; possible teaching interventions needed 3) Implementation: outcome not desired; unstable client; require frequent assessment and evaluation 4) Implementation: outcome not desired; unstable client; required assessment, evaluation, teaching and judgment

The nurse observes a student nurse caring for a client with a tracheostomy and humidified oxygen. Which of the following actions taken by the student nurse requires an intervention by the nurse? 1. The student nurse sets the wall suction to 160 mm Hg pressure prior to suctioning. 2. The student nurse increases the oxygen level to 100% prior to suctioning. 3. The student nurse uses a catheter half the size of the tracheostomy opening. 4. The student nurse tells the client to breathe normally as the catheter is inserted.

1) CORRECT-Implementation: outcome not desired; will cause trauma to tracheobronchial mucosa; suction should be set at 80-120 mm Hg 2) Implementation: outcome desired; will decrease the risk of tissue hypoxia; is standard of care; must remember to decrease oxygen level to ordered concentration after suctioning 3) Implementation: outcome desired; a larger catheter will obstruct the lumen and increase the risk of trauma 4) Implementation: outcome desired; should breathe normally during suctioning

The husband of an elderly client who is incontinent asks the nurse whether his wife will have to wear diapers. Which response, if made by the nurse, is MOST appropriate? 1. "Let's discuss your specific concerns about your wife." 2. "Have you tried any type of incontinence pads in the past?" 3. "Let's wait and see if incontinence pads are necessary." 4. "There are many brands of adult diapers available for you to try."

1) CORRECT-Outcome desired; open-ended; client can verbalize concerns 2) Outcome not priority; need to address husband's immediate concerns; is "yes/no" answer 3) Outcome not desired; need to deal with the "here and now" 4) Outcome not desired; non-therapeutic; dismisses concerns

A 50-year-old man scheduled for a vasectomy asks the nurse if he will be able to have sexual intercourse when he recovers from the surgery. Which statement, if made by the nurse, would be MOST accurate? 1. "My understanding is that each case is different after this procedure." 2. "There will be a short period of time during which you will be unable to sustain an erection." 3. "Most couples find that their sexual activity is more spontaneous after a vasectomy." 4. "This surgery should have no permanent effect on your sexual functioning."

1) Dismisses concerns 2) Provides incorrect information 3) Provides false reassurance 4) CORRECT- Provides factual answer

The home health nurse is planning client visits for the day. Which of the following clients should the nurse see FIRST? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain medication.

1) Follow-up required, but not priority; see second 2) Will require assessment and teaching, but no immediate care indicated; see third 3) CORRECT-Rapid weight gain indicates fluid retention, which could exacerbate CHF; see first 4) Stable client; pain control will be addressed but not first; see last

A 60-year-old male client awakens frightened and agitated. He climbs out of bed, removes his indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following is the FIRST action the nurse should take? 1. Notify the healthcare provider. 2. Restrain the client. 3. Replace the urinary catheter. 4. Check for injuries.

1) Implementation: outcome desired but not priority; assessment needed 2) Implementation: outcome not desired; restraint is last resort; needs reorientation 3) Implementation: outcome desired but not priority 4) CORRECT- Assessment: outcome desired and priority; will guide further assessment and interventions; will gather needed information to tell health care provider

A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets 50,000/mm3, white cell count 1,500/mm3. Which order will should the nurse implement FIRST? 1. "Infuse 2 units of packed red cells." 2. "High-protein, high-carbohydrate diet as tolerated." 3. "Administer 2 units platelets." 4. "Place the client on neutropenic precautions."

1) Implementation: outcome desired but not priority; given when hemoglobin is down to 8 g/dL 2) Implementation: outcome desired but lower priority 3) Implementation: outcome desired but lower priority; risk of spontaneous bleeding when platelets 20,000/mm3 or below 4) CORRECT- Implementation: outcome desired and high priority; at risk for acquiring life-threatening infection due to leukopenia

The nurse enters a client's room and discovers the client is having difficulty breathing because the tracheostomy tube has become dislodged. Which is the INITIAL action the nurse should take? 1. Perform mouth-to-stoma breathing. 2. Extend the client's neck. 3. Place the client in high-Fowler's position. 4. Administer oxygen.

1) Implementation: outcome desired but not priority; needs airway first; difficult to ventilate without neck extension 2) CORRECT- Implementation: outcome desired and priority; provides patent airway; call for help; place supine, then check breath sounds; use hemostat to open airway 3) Implementation: outcome desired but not priority; needs airway first 4) Implementation: outcome desired but not priority; needs airway first

The nurse cares for a client in the cardiac care unit who had cardiopulmonary arrest 2 hours ago and was successfully resuscitated by emergency personnel. As the nurse enters the room, the client develops ventricular fibrillation and is unresponsive to loud spoken voice. Which of the following is the INITIAL action the nurse should take? 1. Ventilate the client with a manual resuscitator bag. 2. Defibrillate the client. 3. Administer sodium bicarbonate intravenously. 4. Begin chest compressions.

1) Implementation: outcome desired but not priority; no cardiac output present during ventricular fibrillation 2) CORRECT- Implementation: outcome desired; immediate return to normal rhythm needed; fatal within 5 minutes if not corrected 3) Implementation: outcome not desired; used to correct metabolic acidosis; priority is to terminate dysrhythmia 4) Implementation: outcome not desired as initial action; defibrillation is priority

The home care nurse observes an elderly woman on a low-sodium diet eating a dill pickle that her son gave her with lunch. Which response by the nurse is MOST appropriate? 1. "Giving your mother salty food will only make her condition worse." 2. "Didn't your mother tell you she's on a low-sodium diet?" 3. "Tell me what you know about your mother's diet." 4. "Let's make an appointment for you to meet with a dietician."

1) Implementation: outcome desired but not priority; non-therapeutic; closed statement 2) Assessment: outcome not desired; "yes/no" question; non-therapeutic 3) CORRECT-Assessment: outcome desired; teaching opportunity; includes family in teaching 4) Implementation: outcome not desired; "passing the buck"

The nurse cares for a 24-year-old female client admitted to an inclient treatment unit with a diagnosis of purging-type bulimia. It is MOST important for the nurse to take which action? 1. Encourage the client to verbalize feelings about eating disorders. 2. Sit with the client in silence as she discusses her daily life and eating habits. 3. Ask the family to describe the client's eating habits prior to admission. 4. Ask the client about any emotional distress she may be experiencing.

1) Implementation: outcome desired but not priority; priority is to establish trust 2) CORRECT- Implementation: outcome desired; establishing trust relationship is first priority 3) Assessment: outcome not desired; more important to establish trust 4) Assessment: outcome desired but not priority; may be done after trust relationship established

The nurse cares for a client with suspected subarachnoid hemorrhage who had a bilateral carotid angiogram 2 hours ago. Which finding requires an intervention by the nurse? 1. The client requests a large glass of water. 2. The client lies quietly in bed with a cloth placed over the forehead and eyes. 3. The head of the bed is elevated 30° and the client's legs are bent at the knee. 4. The urine specific gravity is 1.025.

1) Implementation: outcome desired; client is NPO before the procedure; risk of dye-induced nausea and vomiting; encourage fluid to decrease risk of dye-induced nephrotoxicity after the procedure 2) Implementation: outcome desired; photophobia common after subarachnoid hemorrhage 3) CORRECT-Implementation: outcome not desired and is priority; leg should be extended and in a neutral position after femoral angiogram 4) Assessment: outcome not desired but not priority; urine is concentrated; fluids encouraged to flush dye through kidneys

The nurse reviews room assignments for 4 clients admitted to the unit. The nurse should question which room assignment? 1. A child with chickenpox placed in a private room at the end of the hall. 2. A child with meningitis placed in a private room across from the nurses' station. 3. A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed with type 1 diabetes. 4. A client with essential hypertension placed in a semi-private room with a client who has pancreatitis.

1) Implementation: outcome desired; communicable disease, appropriate room placemen 2) Implementation: outcome desired; communicable disease, requires frequent assessment; client at risk for seizures 3) CORRECT- Implementation: outcome not desired; don't put a client with infection (cellulitis) with a client who is at risk for infection 4) Implementation: outcome desired; appropriate placement, no cross-contamination

An adolescent is admitted to the hospital with a diagnosis of bacterial meningitis. Which of the following actions, if observed by the nurse, would require an intervention? 1. The LPN/LVN enters the client's room and leaves the door open. 2. The nursing assistive personnel leaves the client's room with the face mask hanging from the neck. 3. The student nurse washes hands and puts on gloves. 4. The client's mother stands away from the client while talking to the client.

1) Implementation: outcome desired; droplet precautions necessary, door may be left open 2) CORRECT- Implementation: outcome not desired; used masks should be discarded inside the client's room 3) Implementation: outcome desired; standard precautions used with all clients 4) Implementation: outcome desired; maintain 3-foot separation from infected client

The nurse instructs a client on 100 mg losartan (Cozaar) and 25 mg hydrochlorothiazide (Hyzaar 100-25) tablets to be taken once daily. Which statement requires an intervention by the nurse? 1. "I will eat more fresh fruits while taking this medication." 2. "I should call my health care provider if I develop swelling of my lips." 3. "I can take this medication with or without food." 4. "I understand that I may develop a dry cough while taking this medication."

1) Implementation: outcome desired; hydrochlorothiazide is potassium-wasting diuretic 2) Implementation: outcome desired; angiotensin receptor blockers (ARBs) may cause angioedema 3) Implementation: outcome desired; may be taken with or without food 4) CORRECT- Implementation: outcome not expected; dry, nonproductive cough may occur with angiotensin-converting enzyme inhibitors (ACE inhibitors), not ARBs

The nurse receives a phone call from a mother who was informed that her 10-month-old child was exposed to chickenpox at the day care center. Which statement, if made by the mother, MOST concerns the nurse? 1. "I will give my child Tylenol if a fever develops." 2. "I plan to wash the crib sheets often with a mild soap and water." 3. "I will keep the baby away from the other children right now." 4. "My 85-year-old grandmother is going to help take care of the baby while I am at work."

1) Implementation: outcome desired; increased risk of Reye's syndrome if aspirin given 2) Implementation: outcome desired; no need for stronger additives; may increase skin irritation 3) Implementation: outcome desired; should be isolated until 6 days after appearance of first vesicles 4) CORRECT- Implementation: outcome not desired; immune system in elderly depressed; increased risk of varicella infection

The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate 22 per minute. Which order should the nurse question? 1. 0.9% sodium chloride water infusion at 150 mL/hour. 2. Epinephrine (Adrenalin) 1 mg bolus intravenously. 3. Monitor urinary output hourly for 24 hours. 4. 50 mL 25% albumin (human) 50 mL intravenously.

1) Implementation: outcome desired; is isotonic; will replace lost blood volume 2) CORRECT-Implementation: outcome not desired; effect is vasoconstriction with further decrease of blood flow to vital organs; used to treat anaphylactic shock 3) Implementation: outcome desired; measuring urinary output meaures renal perfusion; appropriate activity 4) Implementation: outcome desired; is a crystalloid; will expand plasma volume rapidly; must carefully monitor response

A mother brings her 15-month-old infant to the pediatric clinic for immunizations. The mother tells the nurse that the infant has been diagnosed with cancer and is being treated with chemotherapy. The nurse should question the administration of immunization? 1. Hepatitis B (HB). 2. Measles/mumps/rubella (MMR). 3. Inactivated polio (IPV). 4. Diphtheria, tetanus toxoid, and acellular pertussis (DTaP).

1) Implementation: outcome desired; no contraindication 2) CORRECT- Implementation: outcome not desired; live virus, not given to immunosuppressed clients 3) Implementation: outcome desired; no contraindication 4) Implementation: outcome desired; contraindication includes encephalopathy within 7 days

The nurse counsels a woman at 36 weeks gestation who has attended childbirth class in preparation for labor and delivery. Which statement by the client requires an intervention by the nurse? 1. "I now know when to expect discomfort during labor and delivery and the things I can do to decrease the discomfort." 2. "My husband is still concerned that he is not sure what to do during the labor process." 3. "Even though I learned pain control techniques, I still may need some pain medication during labor and delivery." 4. "The breathing patterns I learned in class will decrease the amount of time I spend in labor."

1) Implementation: outcome desired; purpose of childbirth class is to eliminate fear of the unknown 2) Implementation: outcome not desired but not priority; focus of class is on fetus and mother; further assessment needed 3) Implementation: outcome desired; anxiety and pain reduction techniques included in class, but mothers are encouraged to use analgesia if needed 4) CORRECT-Implementation: outcome not desired; breathing techniques may decrease anxiety and pain but have no effect on time of labor

An elderly woman is being seen by the home care nurse following a partial gastrectomy for cancer. Which statement, if made by the client, requires further teaching? 1. "The healthcare provider told me to come in once a month for vitamin B12 injections." 2. "I eat frequently throughout the day." 3. "I do not eat concentrated sweets." 4. "I drink several glasses of iced tea with my meals."

1) Implementation: outcome desired; required monthly to prevent pernicious anemia 2) Implementation: outcome desired; small, frequent feeding prevents dumping syndrome 3) Implementation: outcome desired; prevents dumping syndrome 4) CORRECT-Implementation: outcome not desired; drinking fluids with meals causes stomach content to empty too rapidly into the jejunum

The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? 1. "The skin around the stoma should be cleaned with warm water and thoroughly dried." 2. "The appliance should fit snugly around the ileostomy opening." 3. "I should take polyethylene glycol (MiraLax) with a large glass of water." 4. "I will continue to take a daily multi-vitamin."

1) Implementation: outcome desired; standard of care for ileostomy 2) Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of skin irritation 3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract 4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy

The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake." 4. "I should read food and nonprescription medication labels to check the ingredients."

1) Implementation: outcome desired; would indicate fluid retention 2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF 3) CORRECT - Implementation: outcome not desired; salt substitutes contain potassium; spironolactone is a potassium-sparing diuretic 4) Implementation: outcome desired; some medications may contain sodium and potassium

The nurse teaches elderly residents of an assisted-living facility about wellness and health promotion. The nurse is MOST concerned about which statement by one of the residents? 1. "My health care provider tells me I may need the chickenpox vaccine." 2. "I get my flu shot every year in November at a local pharmacy." 3. "I got a pneumonia vaccine about 10 years ago." 4. "The last time I got an injection in my arm, it felt hot and swollen for a day."

1) Implementation: outcome may be desired but is not priority; varicella vaccine recommended for adults who are not immune to varicella or who are immunocompromised; need further assessment 2) Implementation: outcome desired but not priority; should be given earlier in the winter; yearly influenza vaccine recommended for older adults 3) CORRECT- Implementation: outcome not desired and is problem; vaccine 6 years ago or more needs to be repeated; elderly at great risk for streptococcal pneumonia 4) Implementation: outcome: needs follow-up but not of MOST concern.

The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen activator (rtPA). The nurse is MOST concerned if the client makes which of the following statements? 1. "I take a multivitamin tablet daily for cold and flu prevention." 2. "I had major abdominal surgery a year ago." 3. "I get some stomach pain when I eat spicy foods." 4. "I hit my head and lost consciousness during a car accident 2 months ago."

1) Implementation: outcome not a problem; no interaction 2) Implementation: outcome not a problem; surgery within 3 weeks is potential contraindication 3) Implementation: outcome not a problem; active peptic ulcer disease is potential contraindication; needs further investigation 4) CORRECT-Implementation: outcome a problem; significant traumatic head injury within 3 months is an absolute contraindication for thrombolytic therapy

The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? 1. 20 mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (Ambien) at bedtime.

1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant 2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension 3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain 4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors

A 7-year-old boy is brought to the emergency room by his mother following a fall from his bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a careless child; he's always having accidents or fights with his brother." Which response by the nurse would be MOST appropriate? 1. "When I document information about these injuries, it will be on your son's hospital record forever." 2. "How would you describe your son's relationship with his brothers and sisters?" 3. "What I see suggests that someone has been abusing your son." 4. "I will need to talk to the nurse manager about this situation before you leave."

1) Implementation: outcome not desired and not priority; documentation of suspected abuse should contain facts and be nonjudgmental 2) Assessment: outcome not priority; priority action is to report potential abuse to nurse manager 3) Implementation: outcome not desired; close-ended statement; confrontational 4) CORRECT-Implementation: outcome desired; follows chain of command; potential abuse situation

A mother brings her 2-month-old infant to the emergency room. The mother states that her daughter has an elevated temperature and "hasn't kept anything down since yesterday." Which nursing action is MOST appropriate? 1. Administer 0.9% NaCl at 30 mL/hour. 2. Inquire if the child was delivered prematurely. 3. Offer the infant 4 oz of oral rehydration solution (ORS). 4. Ask if the child's older siblings have been ill.

1) Implementation: outcome not desired at this time; offer oral rehydration therapy first; continue to assess fluid and electrolyte balance; may use if severe dehydration or shock noted 2) Assessment: outcome not priority; need to meet physical needs for fluids to prevent or treat dehydration 3) CORRECT- Implementation: outcome desired; offer oral rehydration therapy first with moderate dehydration 4) Assessment: outcome not priority

A man diagnosed with a stroke develops dysphagia. Before allowing the client to eat, which action should the nurse take FIRST? 1. Place client in semi-Fowler's position. 2. Auscultate bowel sounds. 3. Check client's gag reflex. 4. Offer to cut client's food.

1) Implementation: outcome not desired but not priority; should be in high-Fowler's position during and 30 minutes after eating; not first action; assessment should be done first 2) Assessment: outcome desired but not priority; should be assessed, but is not first action 3) CORRECT-Assessment: outcome desired and priority; touch tongue depressor to back of throat; first priority to determine risk of aspiration 4) Implementation: outcome not desired; should keep independent

The home care nurse instructs the daughter of a client diagnosed with congestive heart failure. The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the healthcare provider just prescribed furosemide (Lasix) 40 mg. Which statement, if made by the daughter to the nurse, indicates teaching is successful? 1. "I'm glad that Dad doesn't have to change his diet." 2. "Dad is going to have to eat more cottage cheese and add some more salt to his diet." 3. "Dad must increase his intake of cheese and yogurt." 4. "I should encourage Dad to eat more fresh fruits and vegetables."

1) Implementation: outcome not desired; Lasix is a potassium-wasting diuretic, hypokalemia may precipitate digitalis toxicity 2) Implementation: outcome not desired; high in sodium, would increase fluid retention 3) Implementation: outcome not desired; high in calcium, no indication to increase calcium in the diet; dairy products are high in sodium 4) CORRECT-Implementation: outcome desired; good source of potassium, decreased potassium can predispose to digitalis toxicity

The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task? 1. Ambulate a client 8 hours after a thoracotomy. 2. Give an enema to a client prior to a colonoscopy. 3. Complete a bed bath for a client with burns on the arms and legs. 4. Perform a dressing change on a client 3 days after a cholecystectomy.

1) Implementation: outcome not desired; RN needs to frequently assess and evaluate 2) Implementation: outcome not desired; standard, unchanging procedure, assign to assistive personnel 3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do thorough assessment during bath 4) CORRECT- Implementation: outcome desired; stable client with an expected outcome

A 26-year-old woman comes to the emergency room for a possible ruptured ectopic pregnancy. On admission, the client's vital signs are pulse 90, blood pressure 110/70, respirations 20. A half-hour later, her vital signs are pulse 120, blood pressure 86/50, respirations 26. Which of the following is the MOST appropriate initial action for the nurse to take? 1. Administer pain medication. 2. Increase the rate of the IV fluids. 3. Ask the client to identify where she is. 4. Check the client's white cell count.

1) Implementation: outcome not desired; address ABCs first; analgesic medication may cause further decrease in blood pressure 2) CORRECT-Implementation: outcome desired and priority; increased pulse, decreased BP indicates decreased intravascular volume; symptoms of hypovolemic shock 3) Assessment: outcome desired but not priority; client in shock, implementation required 4) Assessment: outcome desired but not priority; usually won't change unless infection is causing septic shock

A client is admitted to a medical unit with a diagnosis of pneunocystis jiroveci pneumonia. A nurse from another client care area asks the nurse caring for this client about the client's condition. Which is the MOST appropriate statement for the nurse to make? 1. "I will give a brief report on the client's condition in private." 2. "You can get an update by reading the client's chart." 3. "I cannot discuss this client's condition with you." 4. "Why do you want to know about this client's condition?"

1) Implementation: outcome not desired; breaks confidentiality 2) Implementation: outcome not desired; breaks confidentiality 3) CORRECT- Implementation: outcome desired; keep information confidential 4) Assessment: outcome not priority; no need to ask this

The nurse feeds the client in a chair when the client suddenly begins to choke on food. The client is conscious but unable to speak. Which action is MOST appropriate for the nurse to take? 1. Encourage the client to cough and breathe deeply. 2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind. 3. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the client's thighs. 4. Apply several vigorous back blows until the food dislodges.

1) Implementation: outcome not desired; can't inhale, can't exert enough pressure 2) CORRECT-Implementation: outcome desired; abdominal thrust maneuver appropriate when client not moving air 3) Implementation: outcome not desired; no time to do this 4) Implementation: outcome not desired; could cause increased problems; food could migrate further into respiratory tract

The nurse supervises the distribution of meal trays on a medical unit. Which tray will should be given to a client who has requested a kosher diet? 1. Cheeseburger, sliced tomato, french fries, and a milkshake. 2. Pork chops, applesauce, baked potato, and ginger ale. 3. Shrimp salad, sliced avocado, bread, and coffee. 4. Fruit salad, cottage cheese, crackers, and tea.

1) Implementation: outcome not desired; cannot eat dairy and meat at the same meal; eat dairy 6 hours after meat meal 2) Implementation: outcome not desired; cannot eat pork products (bacon, ham, animal shortening, gelatin or foods containing gelatin, e.g., marshmallows) 3) Implementation: outcome not desired; cannot eat shellfish or scavenger fish; fish must have scales 4) CORRECT- Implementation: outcome desired; kosher diet follows Jewish law; no meat or poultry at the same meal as dairy, or using the same utensils; no pork products; no scavenger fish

The nurse reviews medications with a 35-year-old female. The client takes 200 mg carbamazepine (Tegretol) orally twice daily. The client asks the nurse about future pregnancies. Which statement by the nurse is MOST appropriate? 1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get pregnant." 2. "It is recommended that you take carbamazepine suspension instead of the tablets when trying to get pregnant." 3. "You should contact your health care provider and discuss your concerns about pregnancy." 4. "If you avoid drinking grapefruit juice, there should be no problem with conception."

1) Implementation: outcome not desired; carbamazepine and valproic acid increase risk of birth defects; daily folic acid decreases risk of neural tube defects if taken during pregnancy; folic acid will not increase fertility 2) Implementation: outcome not desired; possible birth defects due to action of the medication; route of administration does not matter 3) CORRECT - Implementation: outcome desired; carbamazepine may be teratogenic; the health care provider should discuss risks and benefits with client 4) Implementation: outcome not desired; grapefruit juice can increase serum levels of carbamazepine as much as 40%

During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation? 1. Administer the Ceclor as ordered; do not administer the naproxen. 2. Administer the naproxen as ordered; do not administer the Ceclor. 3. Administer both the Ceclor and naproxen as ordered; document the client's response. 4. Do not administer the Ceclor or naproxen; notify the healthcare provider.

1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins 2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin allergies 3) Implementation: outcome not desired; both medications should be withheld due to allergies 4) CORRECT - Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction

A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram? 1. Clean and shave the catheter insertion-site area. 2. Locate and note the presence of peripheral pulses. 3. Encourage the client to increase oral fluid intake. 4. Teach coughing and deep-breathing exercises.

1) Implementation: outcome not desired; cleansing may be done according to facility policy; shaving may not be recommended due to possible abrasions and increased risk of infection 2) CORRECT - Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses 3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal toxicity 4) Implementation: outcome desired but not highest priority; not at greatly increased risk for atelectasis

A registered nurse from a surgical floor is reassigned to a medical unit. Which of the assignment is MOST appropriate for this nurse? 1. A client with type 1 diabetes mellitus scheduled for discharge at 2 P.M. 2. A client admitted 4 hours ago with a diagnosis of myocardial infarction. 3. A client with Alzheimer's disease who requires a tube feeding. 4. A client admitted yesterday with a diagnosis of left-sided cerebral vascular accident.

1) Implementation: outcome not desired; client requires discharge instructions 2) Implementation: outcome not desired; client requires frequent assessment 3) CORRECT- Implementation: outcome desired; stable client with an expected outcome 4) Implementation: outcome not desired; client requires frequent assessment

The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action? 1. Leave the television on all day in the client's room. 2. Frequently inform the client of the room and bathroom location. 3. Provide the client with newspapers and magazines. 4. Assign a staff member to check on the client every 15 minutes.

1) Implementation: outcome not desired; does not address orientation needs; risk of overstimulation; television should be on intermittently 2) CORRECT - Implementation: outcome desired; provides for safety needs and frequent orientation 3) Implementation: outcome not priority; does not address safety needs or orientation 4) Implementation: outcome desired not priority; addresses safety but not orientation or stimulation needs

The nurse plans care for a 4-year-old girl who has been sexually abused by her grandfather. Play therapy is scheduled as part of the treatment plan. Which statement, if made by the child's parents, indicates understanding of the primary purpose of play therapy? 1. "The main goal of play therapy is for our child to deal with any anger that she has." 2. "During these play sessions, our child will be encouraged to communicate at her own level." 3. "Our child's developmental level will be evaluated by a child development specialist during these sessions." 4. "The main purpose of play therapy is to determine exactly what type of abuse occurred."

1) Implementation: outcome not desired; expression of anger may occur; main goal is communication 2) CORRECT- Implementation: outcome desired; child may not be able to express her perception of the events verbally; play with dolls will facilitate communication 3) Implementation: outcome not desired; not primary goal of play session; assessment of developmental level may occur 4) Implementation: outcome not desired; may occur, but not the primary purpose

The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the client states, "I can't do this." Which response, if made by the nurse, is BEST? 1. "Sure you can do this. You just need to have more practice." 2. "I'll do it for you this time, but you must perform the irrigation the next time." 3. "You seem to be frustrated. What are your specific concerns?" 4. "Most of the other clients learn this without any difficulty. Let's try it again."

1) Implementation: outcome not desired; false reassurance; need to assess first 2) Implementation: outcome not desired; fosters dependence 3) CORRECT-Implementation: outcome not desired; reflects feelings; allows nurse to assess 4) Implementation: outcome not desired; implies deficiency in the client

A man comes into the outclient rheumatology clinic for follow-up care after an episode of acute gouty arthritis. The nurse would be MOST concerned if the client made which of the following statements? 1. "I don't eat shrimp and scallops anymore." 2. "I play softball twice a week without any problem." 3. "I don't go to bars on Friday nights anymore." 4. "I have been drinking SlimFast for breakfast and lunch each day."

1) Implementation: outcome not desired; foods high in purines cause hyperuricemia 2) Implementation: outcome not desired; activity does not precipitate a gout attack 3) Implementation: outcome not desired; excessive drinking precipitates gout 4) CORRECT-Implementation: outcome desired; hyperuricemia may result from prolonged fasting; increases production of ketones, which inhibit normal excretion of uric acid

At 7 A.M., the nurse administers 10 mg glipizide (Glucotrol XL) to a 75-year-old client. At 11 A.M., the nurse notes that the client is drowsy, pale, and has cold, clammy skin. Which is the INITIAL action the nurse will take? 1. Administer 1 mg glucagon subcutaneously. 2. Give the client 1 cup of fruit juice to drink. 3. Determine if the client ate breakfast. 4. Notify the healthcare provider.

1) Implementation: outcome not desired; glucagon used with severe hypoglycemia or when client cannot take oral fluids 2) CORRECT-Implementation: outcome desired; symptoms of moderate hypoglycemia; client can drink juice 3) Assessment: outcome desired but not priority; more important to increase blood glucose level 4) Implementation: outcome desired but not priority; should take action to correct hypoglycemia first

The nurse cares for a client with suspected Neisseria meningitidis infection. Which action is MOST important for the nurse to take? 1. Wear a gown when entering the room. 2. Place the client in a negative-pressure isolation room. 3. Wear a face mask while assisting the client with activities of daily living. 4. Wash hands with soap and water for 3 to 4 minutes when exiting the room.

1) Implementation: outcome not desired; gown not required with droplet precautions unless risk contact with body fluids 2) Implementation: outcome not desired; negative-pressure isolation room used for airborne precautions 3) CORRECT- Implementation: outcome desired; place on droplet precautions because organism spread by larger droplets 4) Implementation: outcome not desired; length of hand-washing does not need to be extended

The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective? 1. Cheeseburger on a whole-wheat bun, french fries, and an apple. 2. Tomato soup, saltines, and a slice of unfrosted angel food cake. 3. Baked cod, biscuit without butter, fruit roll-up. 4. Macaroni and cheese, coleslaw, 2 macaroon cookies.

1) Implementation: outcome not desired; high-fat, high-protein, high-residue; high-residue contraindicated 2) Implementation: outcome not desired; low-fat, low-protein, low-residue 3) CORRECT - Implementation: outcome desired; low-fat, high-protein, low-residue, nonirritating, high in calories, minerals 4) Implementation: outcome not desired; high-fat, low-protein, high-residue; may cause diarrhea

A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and 9, respectively. Which action is MOST appropriate for the nurse to take? 1. Perform nasopharyngeal suctioning. 2. Document the Apgar score. 3. Administer O2 per mask. 4. Rub the infant's back.

1) Implementation: outcome not desired; if Apgar less than 8 and infant is in respiratory distress nasopharyngeal suctioning may be indicated. 2) CORRECT-Implementation: outcome desired; Apgar score of 8 to 10 is considered to be good 3) Implementation: outcome not desired; done if respirations absent or inadequate 4) Implementation: outcome not desired; resuscitative measure, used to stimulate infant

The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse to take which action? 1. Instruct the client to push with the feet while moving client up in bed. 2. Offer the client soft foods on request. 3. Auscultate the client's lungs every 4 hours. 4. Observe the client's legs for warm, reddened, and tender areas every 4 hours.

1) Implementation: outcome not desired; if client holds breath, may increase intracranial pressure 2) Implementation: outcome not desired; need to assess risk for aspiration first before any oral fluids or foods given 3) CORRECT - Assessment: outcome desired and priority; decreased oxygen levels will increase intracranial pressure, client at high risk for aspiration 4) Assessment: outcome desired but not priority; at risk for thrombophlebitis due to immobility

The nurse observes a peer self-administering fentanyl (Sublimaze) after removing it from the narcotic cabinet. Which is the MOST appropriate action for the nurse to take? 1. Tell the nurse what was observed. 2. Report the observation to the supervisor. 3. Complete an incident report. 4. Discuss the incident with another nurse.

1) Implementation: outcome not desired; inappropriate; is confrontational 2) CORRECT- Implementation: outcome desired; use chain of command 3) Implementation: outcome not desired; not appropriate for situation 4) Implementation: outcome not desired; inappropriate; confidential information

A unit of packed cells is ordered for a client who has an intravenous infusion of dextrose 5% in water in progress. Which of the following is the MOST important action for the nurse to take? 1. Connect the packed red blood cells to the dextrose infusion. 2. Remove the dextrose infusion and replace it with the packed red cells. 3. Start a separate infusion of normal saline and use a "Y" connector to infuse the blood. 4. Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

1) Implementation: outcome not desired; incompatible; will cause hypertonic hemolysis (clumping) 2) Implementation: outcome not desired; always start with normal saline (0.9% NaCl) 3) CORRECT- Implementation: outcome desired; isotonic solution; "Y" tubing allows for addition of saline to blood cells and provides access for saline flush if transfusion is interrupted 4) Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take? 1. Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterization every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to a bedside commode every 2 hours.

1) Implementation: outcome not desired; increases risk of infection; catheter-related infections are most common hospital-acquired infection 2) Implementation: outcome not desired; increases chance of infection 3) Implementation: outcome appropriate but not priority; does not keep client independent and active 4) CORRECT - Implementation: outcome desired; keeps client active and independent

A client with a history of gastroesophageal reflux disease reports difficulty sleeping at night. Which of the following is a PRIORITY action for the nurse to take? 1. Instruct the client to drink 8 ounces of milk at bedtime. 2. Advise the client to use 2 pillows at night. 3. Instruct the client to limit fat intake during the day. 4. Advise the client to lie down after the evening meal.

1) Implementation: outcome not desired; increasing stomach volume at bedtime may increase symptoms 2) CORRECT- Implementation: outcome desired; gravity will prevent reflux of stomach contents into esophagus 3) Implementation: outcome not desired; caffeine and spicy foods should be limited 4) Implementation: outcome not desired; lying down will increase reflux of gastric contents

A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic nurse that she was exposed to rubella 2 days ago. Which statement, if made by the nurse, is MOST appropriate? 1. "You need to see the health care provider today, but come in after hours." 2. "Come in this afternoon for your regularly scheduled appointment." 3. "You will receive the rubella vaccine during your regularly scheduled appointment." 4. "Please cancel today's appointment and reschedule for next month."

1) Implementation: outcome not desired; incubation period is 14-21 days, not communicable at this time; if woman develops rubella infection during the first trimester, abortion may be considered 2) CORRECT-Implementation: outcome desired; communicability is approximately 7 days before to 5 days following onset of rash; client needs to be evaluated 3) Implementation: outcome: not desired; vaccination contraindicated for pregnant women; increased risk of fetal complications 4) Implementation: outcome not desired; needs to be seen by the healthcare provider

The nurse cares for clients in a mental health center. The nurse observes the client, formerly homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate? 1. "We don't allow people to take food from the dining room." 2. "What are you going to do with the food?" 3. "We will be serving snacks and juice at 3 P.M." 4. "Let's go watch a movie with the others."

1) Implementation: outcome not desired; judgmental; non-therapeutic communication 2) Assessment: outcome not desired; non-therapeutic; "why" questions make client defensive, feel threatened 3) CORRECT - Implementation: outcome desired; reality orientation; talk with client in non-threatening way about her needs 4) Implementation: outcome not desired; misses opportunity to reality test; distraction used for small children and manic clients

The client with with a 5-year history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. The client is agitated and verbally abusive. Admission orders include chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation. Which action by the nurse is MOST appropriate? 1. Place the client in chest restraints. 2. Assist the client to the bathroom every 2 hours. 3. Assign a licensed practical nurse to stay with the client. 4. Administer disulfram (Antabuse) 500 mg every 12 hours.

1) Implementation: outcome not desired; last resort unless safety is an issue 2) Implementation: outcome desired but not priority; safety is a priority 3) CORRECT - Implementation: outcome desired; nurse should delegate and give specific instructions to LPN/LVN 4) Implementation: outcome not desired; administered to assist the client to refrain from drinking first dose administered at least 12 hours after the last alcohol consumed

The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action? 1. Place the client on her back with thighs flexed on her abdomen. 2. Place the client on her left side with legs flexed. 3. Place the client supine with the head of the bed elevated 30°. 4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; lithotomy position; will not decrease pressure on umbilical cord 2) Implementation: outcome not desired; position used to remove weight of fetus from vena cava to prevent maternal hypotension; will not help with prolapsed cord 3) Implementation: outcome not desired; would aggravate prolapsed cord pressure 4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest position desired to decrease pressure on umbilical cord

A client with suspected active tuberculosis is scheduled for a chest x-ray. Which action, if taken by the nurse, is MOST appropriate? 1. Instruct the staff transporting the client to wear a gown and mask. 2. Place a face mask on the client. 3. Request that the x-ray be postponed. 4. Give the client an emesis basin and tissues.

1) Implementation: outcome not desired; mask is placed on client to prevent transmission of airborne pathogen 2) CORRECT-Implementation: outcome desired and priority; client must wear a standard isolation mask if out of room 3) Implementation: outcome not desired; no reason to postpone, place mask on client 4) Implementation: outcome desired but not priority; mask worn to prevent transmission of airborne pathogen

The client is admitted to the hospital with chest pain when taking deep breaths and peripheral edema. The health care provider's order for the client reads; "Digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is MOST appropriate? 1. Do not administer the second dose of digoxin. 2. Call the health care provider to clarify the order. 3. Administer half the prescribed second dose of digoxin. 4. Administer the first and second dose of digoxin as ordered.

1) Implementation: outcome not desired; medication should be given; if nurse questions the order, the health care provider should be contacted 2) Implementation: outcome not desired; unnecessary; 1 milligram of digoxin is a digitalizing dose; digitalizing dose is necessary to reach therapeutic blood levels 3) Implementation: outcome not desired; nurse can never change prescribed dose 4) CORRECT-Implementation: outcome desired; loading dose to achieve therapeutic blood levels; if loading dose not given, therapeutic levels are not reached for 6 days

While playing on the floor in the hospital room, a 2-year-old has a tonic-clonic seizure. Which action should the nurse take FIRST? 1. Begin oxygen at 2 liters per minute through a nasal cannula. 2. Place a pillow under the client's head. 3. Administer diazepam (Diastat) 5 mg rectally. 4. Turn the client to the side.

1) Implementation: outcome not desired; more important to protect from injury during the seizure; no indication oxygen is needed 2) CORRECT-Implementation: outcome desired; protects client from injuries; stay with client 3) Implementation: outcome not desired; rectal diazepam used to treat status epilepticus in children; not indicated for single seizure 4) Implementation: outcome not desired; turn client to side after the seizure to reduce risk of aspiration; should protect extremities during seizure

The nurse cares for the client immediately after an ileostomy procedure. Which is the best INITIAL action for the nurse to take during client teaching? 1. Schedule the teaching demonstrations during family visits. 2. Encourage the client to discuss any concerns and to ask questions. 3. Show a video demonstrating ileostomy care. 4. Perform care for the ileostomy until the client is able to do it herself.

1) Implementation: outcome not desired; must assess client's readiness to learn first 2) CORRECT - Assessment: outcome desired; ventilate feelings and assess readiness to learn 3) Implementation: outcome not desired; needs to be ready to learn 4) Implementation: outcome not desired; won't assist in adjustment

The nurse cares for a client after a lumbar laminectomy. Which action by the nurse is MOST important? 1. Elevate the head of the bed 30° and then turn the client. 2. Place a pillow between the client's legs and then turn the client. 3. Have the client grasp the side rail on the opposite side of the bed and then assist the client to turn. 4. Instruct the client to bend the knees and then assist the client to turn.

1) Implementation: outcome not desired; must stay flat to maintain alignment 2) CORRECT-Implementation: outcome desired; log roll repositioning maintains proper alignment of spine 3) Implementation: outcome not desired; no twisting allowed 4) Implementation: outcome not desired; no twisting allowed

The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST? 1. "Let's get your mother a walker." 2. "Do you think it's time to put your mother in a nursing home?" 3. "When does your mother fall?" 4. "Does your mother seem to be more confused lately?"

1) Implementation: outcome not desired; need to assess first 2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem 3) CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls 4) Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may be a contributing factor

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back. 2. Elevate the head of the bed 30 degrees. 3. Place the client on her left side with her legs flexed. 4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; no increase in venous return 2) Implementation: outcome not desired; will decrease venous return 3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced 4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena cava will prevent blood return to heart

Two days after admission to an alcoholic treatment unit, a 40-year-old man brags about his binges and boasts that he has not had a steady job in 3 years. Which activity, if selected by the nurse, would be MOST appropriate for this client? 1. Ask the client to lead a group discussion on alcoholism. 2. Ask the client to orient a client to the unit. 3. Encourage the client to play table tennis with other clients. 4. Have the client assume responsibility for the cleanliness of the dining

1) Implementation: outcome not desired; not appropriate at start of treatment 2) Implementation: outcome not desired; later phase; not ready 3) Implementation: outcome not desired; not appropriate at this time in treatment. 4) CORRECT-Have the client assume responsibility for the cleanliness of the dining room.

A 52-year-old homeless woman is admitted to the psychiatric unit for treatment of chronic schizophrenia. The nursing assistive personnel reports to the nurse that when attempting to bathe the client, the client became uncooperative and demanded coffee and a snack. Which suggestion will the nurse give to the nursing assistive personnel? 1. Remind the client that too much caffeine is bad for her health. 2. Tell the client that she may have coffee and a snack when her bath is complete. 3. Remove the client from the bath and return her to bed. 4. Get help from other staff members to complete the bath.

1) Implementation: outcome not desired; not effective with this client 2) CORRECT- Implementation: outcome desired; would meet client's immediate needs; is factual answer 3) Implementation: outcome not desired; needs physical needs met; need to develop trusting relationship; action may increase distress 4) Implementation: outcome not desired; shouldn't use force; client should feel environment is safe; action may increase distress

A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is coaching her during labor. During the transitional phase of labor, the client begins to scream and grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective? 1. Offer the client pain medication before her next contraction. 2. Assist the client to a side-lying position with her knees flexed and a pillow between her legs. 3. Establish eye contact with the client and breathe with her. 4. Suggest to the client that she watch television between contractions.

1) Implementation: outcome not desired; not used during transition; not effective and may interfere with mother's cooperation; may cause respiratory depression in infant 2) Implementation: outcome desired but not priority; priority action is to assist client to get control 3) CORRECT-Implementation: outcome desired and priority; slow breathing, reorient; model appropriate behaviors; this will assist client to get control and reduce muscle tension 4) Implementation: outcome desired but not priority; meet physical needs first

The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST? 1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart." 2. "Tell me what the healthcare provider told you about the risks and benefits of this operation." 3. "Can I answer any questions that you have about the procedure?" 4. "You should read all these materials to be sure that you understand everything about this procedure."

1) Implementation: outcome not desired; nurse should not explain the procedure; the health care provider doing the procedure should explain the risks and benefits 2) CORRECT - Assessment: outcome desired; nurse should determine if client understands risks and benefits of the procedure before the client and nurse sign the informed consent form 3) Implementation: outcome not desired; yes/no question non-therapeutic response 4) Implementation: outcome desired but not priority; reading materials do not ensure that client understands risks and benefits of the procedure

The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia. Which meal, if selected by the client, indicates to the nurse, that teaching is effective? 1. Spaghetti with a sauce of ground beef, cheese, and garlic bread. 2. Baked sausage casserole with rice and sliced tomato. 3. Frankfurter, baked beans, and chopped cabbage salad. 4. Lamb chop, baked potato, and tossed green salad.

1) Implementation: outcome not desired; only beef is a good source 2) Implementation: outcome not desired; only sausage is good source 3) Implementation: outcome not desired; low in iron 4) CORRECT-Implementation: outcome desired; contains 24-30 mg; vitamin C from potato and salad enhance iron availability

The school nurse teaches accident-prevention to the parents of school-aged children. Which statement, if made by a parent to the nurse, indicates teaching is effective? 1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." 2. "I keep my guns and ammunition in a locked cabinet in the basement." 3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars." 4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."

1) Implementation: outcome not desired; only bicycle helmet is recommended; additional protective gear with skateboarding or rollerblading 2) Implementation: outcome not desired; guns and ammunition should be kept in separate locked areas 3) CORRECT-Implementation: outcome desired; injury prevention facilitated by age-appropriate safety education 4) Implementation: outcome not desired; school-aged children are developmentally ready for less supervision; parents should encourage interaction with peers

The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements? 1. "Your parents are going to leave a half hour before the surgery." 2. "You're going to talk with some other children who had this surgery." 3. "If you have this surgery, your parents will buy you a new toy." 4. "Take this doll and show me where the operation will be done."

1) Implementation: outcome not desired; parents are encouraged to remain with child 2) Implementation: outcome not desired; appropriate only for school-aged and adolescent children 3) Implementation: outcome not desired; not appropriate 4) CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment

The nurse cares for a client being maintained on a ventilator. The client suddenly becomes distressed and agitated. Which of the following is the MOST appropriate action for the nurse to take? 1. Obtain an order for a tranquilizer. 2. Restrain the client. 3. Check the last arterial blood gas result. 4. Assess the client's breathing pattern in relation to the ventilator.

1) Implementation: outcome not desired; priority is to determine cause of distress 2) Implementation: outcome not desired; physical restraints are a last resort 3) Incorrect. A current ABG is needed to make any type of decision. 4) CORRECT-Assessment: outcome desired and priority; is client "fighting" the ventilator; symptoms of respiratory distress include restlessness, agitation, apprehension, irritability, pallor, use of accessory muscles, increased pulse; check airway, vital signs, and ABGs

The parents of a newborn boy ask the nurse whether they should have their son circumcised. Which response by the nurse is MOST appropriate? 1. "The benefits of the procedure usually outweigh the risks of bleeding and infection." 2. "You should ask your obstetrician or pediatrician to advise you." 3. "It is not mandatory that your son have a circumcision. What are your concerns?" 4. "Some parents worry about the pain associated with circumcision, but there is actually very little discomfort."

1) Implementation: outcome not desired; program of good hygiene provides advantages without risks of circumcision 2) Implementation: outcome not desired; passing the buck 3) CORRECT-Assessment: outcome priority; open communication; initial assessment: acknowledges parents' feelings 4) Implementation: outcome not desired; closed communication; nurse assumes that pain is the issue

The nurse teaches reality orientation to the husband of a woman with Alzheimer's disease and a moderate hearing loss. Which statement, if made by the client's husband, indicates that he understands this technique? 1. "I should ask my wife about current events we have discussed." 2. "I should reminisce with my wife about past events." 3. "I should frequently ask my wife for the date and time." 4. "I should place a calendar and clock in an obvious place."

1) Implementation: outcome not desired; short-term memory affected; unable to remember 2) Implementation: outcome not desired; will not reorient 3) Implementation: outcome not desired; can cause confusion, anxiety 4) CORRECT-Implementation: outcome desired and priority; use of memory aids and cues to help orientation; gives sense of security

A client is brought to the mental health center reporting severe headaches, insomnia, and poor appetite. Each time a question is asked, the client provides a lengthy, detailed description of events. Which of the following is the MOST important action for the nurse to take? 1. Remind the client of the time. 2. Tell the client that people are there to take care of her. 3. Sit and listen to the client. 4. Ask the client to be brief.

1) Implementation: outcome not desired; should allow client the time to express needs; non-therapeutic response 2) Implementation: outcome not desired; false reassurance; blocks communication 3) CORRECT- Implementation: outcome desired; assess first to meet client needs, allow client to express needs 4) Implementation: outcome not desired; non-therapeutic; nurse is controlling the interview

A 42-year-old woman has a right mastectomy for treatment of breast cancer. The client is returned to her room with a Hemovac drain. Which of the following is the MOST important action for the nurse to take? 1. Open the drain port to provide an air vent. 2. Tape the collection chamber to the client's bed. 3. Compress the evacuator completely after emptying it. 4. Empty the collection chamber every 2 hours.

1) Implementation: outcome not desired; should be closed except when emptying chamber 2) Implementation: outcome not desired; should be secured to client's dressing or clothing, not to the bed 3) CORRECT- Implementation: outcome desired; provides for negative pressure of 45 mm Hg for wound suction 4) Implementation: outcome not desired; should not open unit unnecessarily due to chance of contamination

The nurse observes a man standing with his adult children after the unexpected death of his wife. Which statement by the nurse is MOST appropriate? 1. "I'm sorry about your wife. I'm sure you will miss her." 2. "This must be a difficult time for you; I will stay with you." 3. "I know you're going to miss your wife; would you like to talk about some memories you both shared?" 4. "Is there anything I can get for you?"

1) Implementation: outcome not desired; should focus on husband, not nursing staff; assumes husband's feelings 2) CORRECT-Implementation: outcome desired; nurse stays with client; open-ended; responds to feeling tone 3) Implementation: outcome not desired; should focus on here and now; assumes husband's feelings 4) Assessment: outcome desired but not priority; "yes/no" question; does not respond to feeling tone

The healthcare provider orders furosemide (Lasix) and spironolactone (Aldactone). Prior to administering Lasix and Aldactone, the nurse determines that the client's potassium level is 3.2 mEq/L. Which is the MOST important action for the nurse to take? 1. Hold the furosemide and spironolactone. 2. Administer only the spironolactone. 3. Administer only the furosemide. 4. Administer the furosemide and spironolactone.

1) Implementation: outcome not desired; should give Aldactone, K+-sparing diuretic 2) CORRECT- Implementation: outcome desired; K+-sparing diuretic; should contact health care provider about serum potassium 3) Implementation: outcome not desired; will lose more potassium 4) Implementation: outcome not desired; will lose more potassium

The nurse performs dietary teaching for a client taking lithium carbonate (Lithonate). Which snack, if selected by the client, indicates that teaching is effective? 1. Four carrot sticks. 2. 8 oz of ice tea. 3. A whole banana. 4. 12 oz of lemonade.

1) Implementation: outcome not desired; should provide increased fluid intake 2) Implementation: outcome not desired; contains caffeine, which is a natural diuretic and stimulant; should avoid fluids containing caffeine 3) Implementation: outcome not desired; should provide increased fluid intake 4) CORRECT-Implementation: outcome desired; provides for increased fluid intake; lithium can cause nephrogenic diabetes insipidus; those on lithium experience thirst and polyuria; need 2,500-3,000 mL/day with adequate salt intake

The nurse teaches a client who had an above-knee amputation (AKA) 2 days ago about how to care for the residual limb. Which statement, if made by the client, indicates to the nurse that the teaching is effective? 1. "I shall apply cream to the residual limb to soften the skin." 2. "I should rewrap my residual limb with elastic bandages 3 times a day." 3. "I will not be able to sleep on my stomach from now on." 4. "I will no longer be able to sit in straight back chairs at home."

1) Implementation: outcome not desired; skin needs to be toughened if prosthesis is going to be used; no lotions, creams, or powders should be used unless prescribed 2) CORRECT-Implementation: outcome desired; bandages may be loose; expose to air 20 min/day; inspect residual limb for redness, irritation 3) Implementation: outcome not desired; the prone position will decrease the risk of flexion contractures 4) Implementation: outcome not desired; client can sit in straight back chair; time should be restricted to 1 hour or less

The nurse monitors the activities of a 9-year-old girl with juvenile rheumatoid arthritis (JA). Which activity is MOST appropriate? 1. The girl is jumping rope. 2. The girl is skipping. 3. The girl jumps off the end of a slide. 4. The girl participates on a swim team.

1) Implementation: outcome not desired; too traumatic to the joints 2) Implementation: outcome not desired; too traumatic to the joints 3) Implementation: outcome not desired; too traumatic to the joints 4) CORRECT-Implementation: outcome desired; good moving and stretching activity; also, throwing or kicking a ball, riding a bicycle, swimming

The healthcare provider has ordered a fenestrated tracheostomy tube to be capped. Which is the MOST important action for the nurse to take before the tracheostomy tube is plugged? 1. Administer 100% oxygen. 2. Deflate the cuff of the tracheostomy tube. 3. Suction the tracheostomy tube. 4. Administer humidified oxygen.

1) Implementation: outcome not desired; unnecessary in this situation; done before suctioning 2) CORRECT- Implementation: outcome desired; allows for an airway 3) Implementation: outcome not desired; perform only as needed for congestion 4) Implementation: outcome not desired; when O2 is administered, it should be humidified, though O2 is not required in this situation

The nurse describes to a male client how to collect a clean-catch urine for culture and sensitivity. Which explanation, if made by the nurse, is MOST accurate? 1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary drainage catheter is inserted to obtain urine." 2. "You will be asked to empty your bladder one half-hour before the test; you will then be asked to void into a container." 3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then voided into a sterile container; the container must not touch the penis." 4. "You must void a few drops of urine, and then stop; then void the remaining urine into a clean container which should be immediately covered."

1) Implementation: outcome not desired; unnecessary to use catheter 2) This is the procedure for a double void specimen and the question is for a clean catch specimen. 3) CORRECT-Implementation: outcome desired; a culture and sensitivity urinalysis is a sterile specimen 4) Implementation: outcome not desired; need sterile container

The nurse cares for the client diagnosed with Parkinson's. The nurse notes that the client is ambulating with short, accelerating steps. Which action is the MOST appropriate for the nurse to take? 1. Offer the client a wheelchair. 2. Provide the client a walker. 3. Suggest that the client wear comfortably fitting shoes. 4. Teach the client to walk with a broad-based gait.

1) Implementation: outcome not desired; would make the client dependent 2) Implementation: outcome not desired; client needs to alter method of walking 3) Implementation: outcome not desired 4) CORRECT- Implementation: outcome desired; concentrate on walking erect with eyes on horizon

One afternoon in the hospital day room, the nurse overhears a woman with chronic schizophrenia say to another other client, "I hate you, get away from me or I'll kill you." Which of the following responses, if made by the nurse, is MOST appropriate? 1. "I will not let that client hurt you." 2. "There is no reason for you to be angry with that client." 3. "You seem to be frightened by that client." 4. "You don't really want to kill that client."

1) Non-therapeutic; false reassurance 2) Non-therapeutic; assumes client is angry because she is feeling threatened 3) CORRECT-Therapeutic; acknowledges feelings 4) Non-therapeutic; don't argue with client

The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN? 1. A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy. 2. A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a 24-hour history of watery diarrhea. 3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago. 4. A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.

1) Outcome not desired; requires frequent assessment of neuromuscular function and monitoring response to therapy 2) Outcome not desired; elderly clients are at risk for clostridium difficile infection due to antibiotic therapy; client would need frequent assessment and evaluation 3) CORRECT - Outcome desired; LPN/LVN can care for stable clients with expected outcomes; nothing in question indicates instability; as cerebral edema resolves, the condition will improve 4) Outcome: not desired; client requires frequent assessment and evaluation; WBC indicates possible infection

The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.

1) Outcome not priority; indicates that Rh antibodies present; needs further investigation 2) CORRECT - Outcome priority; indicates pre-eclampsia; requires immediate evaluation; is at risk for complications 3) Outcome not priority; colostrum may leak from breast during pregnancy; normal finding 4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in primagravidas; 20 weeks in multigravidas

The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST? 1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute. 2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute. 3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. 4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.

1) Potential for hemorrhage or fatty embolism; eliminate second 2) Potential pneumothorax; see second 3) CORRECT - Real problem; vitals signs indicate significant increase in intracranial pressure; most unstable client 4) Most stable client; eliminate first

A nurse is performing triage in the emergency department. Which of the following clients should the nurse see FIRST? 1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).

1) See last; most stable client 2) See second; unstable client; cardiovascular; requires further assessment and antihypertensive medication 3) CORRECT-See first; unstable client; upper airway injury possibly due to inhalation injury 4) See third; vital signs consistent with dehydration, rapid respiration is Kussmaul's and expected

A 56 year old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?

A nurse with marfran's syndrome who is postmenopausal. A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any one staff member's exposure to the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the immune response in the client who should not be exposed to the potential inadvertent transmission of an infectious organism (D).

The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?

A pregnant woman A pregnant woman's (A) metabolic demands are 20 to 24% more than the basic metabolic rate. (B, C, and D) require only 15 to 20% more than the basic metabolic rate.

A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred?

A sudden gush of dark blood from the introitus Rationale: Placental separation occurs when the placenta separates from the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual. Test-Taking Strategy: Use the process of elimination and focus on the subject, placental separation. Try visualizing this physiological process as a means of finding the correct option. Review the signs of placental separation if you had difficulty with this question.

The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first?

A victim with an open fracture of the arm that is bleeding profusely

39 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. A. "I need to avoid salt in my diet." B. "It's fine to take any over-the-counter medication with the lithium." C. "I need to come back the clinic to have my lithium blood level checked." D. " I should drink 2 to 3 quarts of liquid every day." E. "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A. "I need to avoid salt in my diet." Correct B. "It's fine to take any over-the-counter medication with the lithium." Correct E. "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." Correct

6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you're feeling." B. "That's a normal response after this type of surgery." C. "It will take time, but, I promise you, you will get over this depression." D. "Every client who has this surgery feels the same way for about a month."

A. "Tell me more about what you're feeling."

23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? A. "What are your feelings right now?" B. "Why don't you feel like washing up?" C. "You aren't talking today. Cat got your tongue?" D. "You need to get yourself cleaned up. You have company coming today."

A. "What are your feelings right now?"

12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: A. 3 minutes B. 10 seconds C. 15 seconds D. 30 minutes

A. 3 minutes Correct

18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A. A lower abdominal incision B. An upper abdominal incision C. An incision made in the perineal area D. The urethra, with the use of a cutting wire

A. A lower abdominal incision

5.NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water B. Withhold the antihypertensive and administer it at bedtime C. Administer the medication by way of the intravenous (IV) route D. Hold the antihypertensive and resume its administration on the day after the ECT

A. Administer the antihypertensive with a small sip of water

25 An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? A. Administering 100% oxygen B. Having a crisis counselor available C. Instituting suicide precautions for the client D. Obtaining blood for determination of the client's carboxyhemoglobin level

A. Administering 100% oxygen

26 A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? A. Anxiety B. Powerlessness C. Disruption of thought processes D. Inability to maintain health

A. Anxiety

73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? A. Anxiety Correct B. Premature grief C. Fluid volume loss D. Fluid volume overload

A. Anxiety

114 -A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? A. Assessing the client for organic causes of loss of arm movement B. Calling the crisis intervention team and asking them to assess the client C. Performing active and passive range-of-motion (ROM) exercises of the client's arms D. Asking the client to move his arms and documenting the loss of movement he has experienced

A. Assessing the client for organic causes of loss of arm movement

37 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. A. Beer B. Apples C. Yogurt D. Baked haddock E. Pickled herring F. Roasted fresh potatoes

A. Beer Correct C. Yogurt Correct E. Pickled herring Correct

8 A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray B. Check the client's blood glucose level to serve as a baseline measurement C. Hang the prescribed bag of PN and start the infusion at the prescribed rate D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency

A. Call the radiography department to obtain a chest x-ray

1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours

A. Checking the client's blood pressure Checking the client's blood pressure Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.

126 A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? A. Contacting the child's physician to report the findings B. Administering acetaminophen (Tylenol) to the child to relieve the pain C. Asking that the child not attend the physical education class until the neck pain has subsided D. Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control

A. Contacting the child's physician to report the findings

47 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: A. Contacting the physician B. Documenting the findings C. Continuing to monitor the client D. Increasing the rate of the infusion

A. Contacting the physician

13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: A. Depression B. Diabetes mellitus C. Hyperthyroidism D. Coronary artery disease

A. Depression

78 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings B. Ask the physician to see the client immediately C. Ask another nurse to check for the uterine fundus D. Place the client in the supine position for 5 minutes, then recheck the abdome

A. Document the findings

34 A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Drinking 2 to 3 L of fluid each day B. Applying heat packs to the affected joint C. Resting and immobilizing the affected area D. Consuming foods high in purines E. Performing range-of-motion exercise to the affected joint three times a day

A. Drinking 2 to 3 L of fluid each day Correct C. Resting and immobilizing the affected area Correct

35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A. Fatigue B. Anemia C. Weight loss D. Low-grade fever E. Joint deformities

A. Fatigue Correct D. Low-grade fever Correct

98 -A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as: A. Fear B. Denial C. Acceptance D. Preoccupation with self

A. Fear

87- A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? A. Fever B. Dizziness C. Flatulence D. Drowsiness

A. Fever

36 A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. A. Fever B. Vasculitis C. Weight gain D. Increased energy E. Abdominal pain

A. Fever Correct B. Vasculitis Correct E. Abdominal pain Correct

92 -A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. A. Hunger B. Weakness C. Blurred vision D. Increased thirst E. Increased urine output

A. Hunger Correct B. Weakness Correct C. Blurred vision Correct

132 -Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: A. Increase fluid intake B. Consume low-fiber foods C. Consume foods that are low in potassium D. Contact the physician if the urine turns yellow-brown

A. Increase fluid intake

91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply A. Keeping the room slightly darkened B. Placing the client in a room with a quiet roommate C. Encouraging isometric exercises if bed rest is prescribed D. Monitoring the client for changes in alertness or mental status E. Restricting visits to close family members and significant others and keeping visits short

A. Keeping the room slightly darkened Correct D. Monitoring the client for changes in alertness or mental status Correct E. Restricting visits to close family members and significant others and keeping visits short Correct

122 -An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply. A. Nausea B. Eye pain C. Vomiting D. Headache E. Diminished central vision F. Increased light perception

A. Nausea Correct B. Eye pain Correct C. Vomiting Correct D. Headache Correct

93- A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: A. Physical and functional abilities B. Feelings about restricted mobility C. Uneasiness about using the crutches D. Understanding of the need for increased mobility

A. Physical and functional abilities

17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? A. Recent stroke B. Hypothyroidism C. History of glaucoma D. Peripheral vascular disease

A. Recent stroke

19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. A. Seek medical advice if you find a skin lesion. B. Use sunscreen with a low sun protection factor (SPF). C. Avoid sun exposure before 10 a.m. and after 4 p.m. D. Wear a hat, opaque clothing, and sunglasses when out in the sun. E. Examine the body every 6 months for possibly cancerous or precancerous lesions.

A. Seek medical advice if you find a skin lesion. D. Wear a hat, opaque clothing, and sunglasses when out in the sun.

58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. A. Skin tenting B. Flat neck veins C. Weak peripheral pulses D. Moist oral mucous membranes E. A heart rate of 88 beats/min F. A respiratory rate of 18 breaths/min

A. Skin tenting Correct B. Flat neck veins Correct C. Weak peripheral pulses Correct

32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply. A. Smoking Correct B. A high-calcium diet C. High alcohol intake Correct D. White or Asian ethnicity Correct E. Participation in physical activities that promote flexibility and muscle strength

A. Smoking Correct C. High alcohol intake Correct D. White or Asian ethnicity Correct

50 A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? A. Spontaneous bruising B. Decrease in uterine size C. Urine output of 30 mL/hr D. Brownish vaginal discharge

A. Spontaneous bruising

81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A. Steak B. Spinach C. Chicken D. Oranges

A. Steak

51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: A. Stops the oxytocin infusion Correct B. Checks the vagina for crowning C. Encourages the client to take short, deep breaths D. Increases the rate of the oxytocin infusion and calls the physician

A. Stops the oxytocin infusion

75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A. Tachycardia Correct B. Cool, clammy skin C. Decreased respiratory rate D. Diminished peripheral pulses Correct E. Urine output of less than 30 mL/hr

A. Tachycardia Correct D. Diminished peripheral pulses Correct

113 -A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior: A. Temporarily eases anxiety in the client B. Is an attempt on the client's part to punish herself C. Is an attempt on the client's part to seek the attention of others D. Is a response by the client to voices telling her that everything is contaminated and that she must engage in this behavior

A. Temporarily eases anxiety in the client

56 A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? A. The client reports a history of sexual abuse by her father. B. The client reports that her relationship with her spouse is stable. C. The client reports a satisfying intimate relationship with her spouse. D. The client reports that her and her spouse have never been able to conceive children

A. The client reports a history of sexual abuse by her father.

A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens?

Abduction device

A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen. Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child?

Acetylcysteine

A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child?

Acetylcysteine (Mucomyst)

The nurse is planning care for a client who is having abdominal surgery. To achieve postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such a turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?

Administer analgesics prior to encouraging progressive activities and ambulation Effective pain management in the postoperative period promotes the client's participation in exercises that promote optimal healing and prevent complications, so the client should be given an analgesic prior to mobilization (C). Although (A) promotes client understanding, it is more important that the client's pain is managed to promote cooperation and compliance in the care plan. (B) is helpful but is not as useful if the client is in pain. (D) may unduly scare the client.

A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse?

Administer isoniazid (INH) daily for 6 to 9 months. Latent TB infection (LTBI) occurs when an individual becomes infected with Mycobacterium tuberculosis but does not become acutely ill, so isoniazid (INH) drug therapy once daily for 6 to 9 months (B) should be implemented to prevent transmission and the development of clinical disease. The nurse is infected and should be treated, not retested (A). Combination therapy (C) is the recommended treatment for active TB. Vaccination (D) is not indicated with infection.

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

Administer the antihypertensive with a small sip of water Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed.

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?

Administering 100% oxygen Rationale: A client with carbon monoxide poisoning is treated with inhalation of 100% oxygen to shorten the half-life of carbon monoxide to around an hour. Hyperbaric oxygen may be required to reduce the half-life to minutes by forcing the carbon monoxide off the hemoglobin molecule. Because the poisoning occurred as a result of a suicide attempt, a crisis counselor should be consulted, but this is not the priority. Suicide precautions should be instituted once emergency interventions have been completed and the client has been admitted to the hospital. The diagnosis is confirmed with a measurement of the carboxyhemoglobin level in the client's blood. Obtaining a blood specimen in which measure the carboxyhemoglobin level is a priority; however, the nurse would immediately administer 100% oxygen to the client.

The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter Which action should the nurse implement?

Admister the dose as prescribed Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose.

The nurse is teaching a client with Addison's disease about this new diagnosis

Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex

Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the:

Albuterol several minutes before inhaling the fluticasone propionate

Fluticasone propionate and albuterol, administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the:

Albuterol several minutes before inhaling the fluticasone propionate

A male client gives a copy of his living will to the nurse...

Allow the client to die with dignity and without life-prolonging techniques.

The nurse is caring for an 8-year-old child who has a chronic illness. The child has a tracheostomy, and a parent is rooming-in during this hospitalization. The parent insists on providing almost all of the child's care and tells the nurses how to care for the child. When planning the child's care, the primary nurse should recognize that the parent is: -controlling and demanding. -assuming the nurse's role. -the expert in care of the child. - not allowing nurses to function independently.

An expert in care of the child.

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?

Anxiety Rationale: Anxiety is vague uneasiness or discomfort that warns of trouble and enables an individual to approach and deal with the threat. Fluid volume loss indicates a hypovolemic state, whereas fluid volume overload indicates a hypervolemic state. Premature grief is a state in which an individual grieves before an actual loss. There is no information in the question to indicate that fluid volume loss, fluid volume overload, or premature grief are factors for concern.

A nurse prepares to administer digoxin to a client with heart failure. Which vital sign must be checked before the medication is administered?

Apical pulse

A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume:

Apple juice

A client with advanced cirrhosis and hepatic encephalopathy is manifesting....

Apply a pressure-relieving mattress under the client.

A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?

Apply a water soluble lubricant to the lips, oral mucosa and nares. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance.

50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion

Applying suction for more than 10 seconds

A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?

Arrest of active phase.

A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care?

Ask client to describe triggers of anger Depression is associated with feelings of anger, and clients are often not aware of these feelings. Awareness is the first step in dealing with anger (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings (B). Anger may persist after beginning antidepressant therapy (A), and it may not be necessary to revise the goal (D). (C) can assist the client to cope, but it's most important to ask the client to describe triggers of anger.

A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the health care provider's answering service and is told that the health care provider is off for the night and will be available in the morning. The nurse should:

Ask the answering service to contact the on-call health care provider Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a health care provider's prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor.

A male client who has been taking propranolol ( inderal) for 18 months tells the nurse the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the use provide?

Ask the health care provider about tapering the drug dose over the next week. Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended.

The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?

Ask the spouse to step out for a few minutes The nurse should ask the spouse to step out of the room (D), which maintains the client's privacy and allows the client to respond, without confronting the spouse. (A) reinforces the spouse's responses. (B) may not eliminate the spouse's responses on behalf of the client. (C) does not foster the nurse-client relationship.

The nurse is caring for a client who is scheduled for surgery in 2 hours

Ask the surgeon to return to clarify questions for the client.

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:

Asking the ED health care provider to check the client Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished with the PVCs themselves because the decreased stroke volume of the premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is essential that the nurse determine whether the premature beats are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client and document the findings, these are not the most appropriate actions of those provided. The most appropriate action would be to ask the ED health care provider to check the client.

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:

Asking the ED physician to check the client

Prior ro the discharge of a family 4-day old newborn the nurse is collecting the blood specimens to screen for phenylketonuria(PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test?

Assess the newborns feeding patterns of formula or breast milk which has come in PKU screening is mandatory in most states and requires that the newborn has ingested adequate amounts (2 to 3 days) of milk proteins (C) to detect metabolism errors, which result in abnormal phenylalanine (an amino acid) in the newborn's blood and predisposes the infant to mental retardation. (A and D) are not necessary. (B) is commonly practiced when infants are discharged at 24-hours of age or before adequate milk proteins have been ingested.

A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse?

Assessing the client for organic causes of loss of arm movement

A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse?

Assessing the client for organic causes of loss of arm movement Rationale: The priority is ruling out any neurological disorders. After it has been determined that there is no physiological basis for the problem, further psychiatric evaluation can be done. Encouraging the client to move his arms and performing active and passive ROM exercises have no beneficial effect in this situation. In fact, either option could be harmful if there is a physiological basis for the client's problem.

(Video) The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next?

Assessing the wound

The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next?

Assessing the wound

a client who has active tuberculosis ( TB) is admitted to the medical unit. What action is most important for the nurse to implement?

Assign the client to a negative air-flow room Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment.

The parents of a 4-month-old infant who is hospitalized...

Assign the same nurse to care for the child each day.

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (PaO2) of less than 60 mm Hg (7.95 kPa). On the basis of the ABG result, the nurse prepares to:

Assist in intubating the client and beginning mechanical ventilation Rationale: A client who sustains smoke inhalation is immediately treated with 100% humidified oxygen, delivered by way of face mask. Endotracheal intubation with mechanical ventilation is needed if the client exhibits respiratory stridor, crowing, or dyspnea, all of which indicate airway obstruction. Normal arterial oxygenation is 80-100 mm Hg (10.6-13.33 kPa). An arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa) is an indication for intubation and mechanical ventilation.

A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which of the following findings indicates to the nurse that the client has sustained flail chest?

Asymmetrical chest movement

Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL (111 umol/L). The nurse interprets this result as:

At the top of the therapeutic range

Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as:

At the top of the therapeutic range

A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis?

Atropine sulfate

A client with myasthenia gravis who has been taking pyridostigmine bromide for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis?

Atropine sulfate

Which information should the nurse give a client with chronic kidney disease (CKD)?

Avoid salt substitutes A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD.

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?

Avoid sharing towels and washcloths with siblings All of the information is important to include in the teaching plan, but it is most important to avoid spreading the bacterial infection. The child should avoid sharing towels and washcloths (D) and should stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of others. (A, B, and C) are important measures to reduce the child's discomfort, but inhibiting the spread of the infection is the priority intervention.

A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide?

Avoid tight-fitting clothing and do not use bubble-bath or bath salts A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated by tight-fitting clothing , underwear, or pantyhose made of nonabsorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-bath or bath salts (D) which further irritate sensitive genital tissue. Douching (A) is not recommended because it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While (B) encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments (C), provide absorbancy and reduce moisture in the perineal area.

109 -Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? A. "I need to limit my intake of fluids while I'm taking this medication." B. "I need to stop the medication and call my doctor if I have severe diarrhea." Correct C. "I can expect skin redness and a rash when I take this medication." D. "I may get a burning feeling in my throat, but it's normal and will go away."

B. "I need to stop the medication and call my doctor if I have severe diarrhea."

102 -A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate? A. "That's all right. I'd stop, too, if it made me feel funny." B. "Tell me more about how the medication was making you feel." C. "Did you let your doctor know that you stopped taking the medication?" D. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that."

B. "Tell me more about how the medication was making you feel."

94- A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate? A. "Have you told your doctor how you feel?" B. "Tell me more about your concerns regarding the tube feedings." C. "Don't worry. We'll keep you in the hospital until you're ready to do them by yourself." D. "We'll ask the doctor about having a visiting nurse come to your home to give you your feedings."

B. "Tell me more about your concerns regarding the tube feedings."

79- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? A. "Many of my antibodies are passed through the placenta." B. "The placenta maintains the body temperature of my baby." C. "Glucose, vitamins, and electrolytes pass through the placenta." D. "It provides an exchange of oxygen and carbon dioxide between me and my baby."

B. "The placenta maintains the body temperature of my baby."

121- A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must: A. Drink fluids to eliminate the dye B. Contact the physician if the skin appears yellow C. Expect that the urine will be bright green until the dye has been excreted D. Wear sunglasses and avoid direct sunlight until pupil dilation returns to normal

B. Contact the physician if the skin appears yellow

116 -A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: A. Severe anxiety B. Conversion disorder C. Posttraumatic stress disorder (PTSD) D. Obsessive-compulsive disorder

B. Conversion disorder

20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? SEE PICS A. B. C. D.

B. Correct

88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? A. Nausea B. Dark urine C. Urinary frequency D. Decreased appetite

B. Dark urine

67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: A. Increase B. Decrease C. Remain unchanged D. Double from what they normally are

B. Decrease

69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: A. Contact the physician B. Document the findings C. Ask the client to walk for 5 minutes, then recheck the reflexes D. Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes

B. Document the findings

40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: A. Contact the physician B. Document the findings C. Institute seizure precautions D. Have a blood specimen drawn immediately for serum lithium testing

B. Document the findings Correct

52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? A. Repositioning the mother B. Documenting the finding Correct C. Notifying the nurse-midwife D. Taking the mother's vital signs

B. Documenting the finding

62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? A. Headache B. Drowsiness C. Photophobia D. Urinary frequency

B. Drowsiness

103- A nurse provides information to a client with peripheral vascular disease about ways to limit the disease's progression. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Crossing the legs at the ankles only B. Engaging in exercise such as walking on a daily basis C. Washing the feet daily with a mild soap and drying them well D. Inspecting the feet at least once a week for injuries, especially abrasions E. Using a heating pad on the legs to help keep the blood vessels dilated

B. Engaging in exercise such as walking on a daily basis Correct C. Washing the feet daily with a mild soap and drying them well Correct

60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: A. Salt substitutes B. Herbs and spices C. Salt with cooking only D. Processed foods as desired

B. Herbs and spices

104 -A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? A. Providing food and fluid as the client requests B. Offering high-calorie and high-protein foods and fluids frequently throughout the day C. Completing the dietary menu for the client to ensure that adequate nutrition is provided D. Weighing the client daily so that the client may determine whether the nutritional plan is working

B. Offering high-calorie and high-protein foods and fluids frequently throughout the day

22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? A. Anxiety B. Powerlessness C. Ineffective coping D. Disturbed body image

B. Powerlessness

71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: A. Notify the physician B. Recheck the temperature in 4 hours C. Encourage the client to breastfeed the newborn D. Institute strict bedrest for the client and notify the physician

B. Recheck the temperature in 4 hours

108- A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to: A. Stay with the client and observe her behavior B. Take the client to the bathroom and provide her with a warm bath C. Tell the client that it is time for sleep and that she needs to go to her room D. Tell the client that other clients are trying to sleep and that she is being disruptive

B. Take the client to the bathroom and provide her with a warm bath

The nurse instills an atropine phthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate?

Blurred vision

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child

Body surface area

A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child:

Boiled Rice

A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child:

Boiled rice

A nurse reviews the results of a total serum calcium determination in a client with chronic kidney disease. The results indicate a level of 12.0 mg/dL (3 mmol/L). In light of this result, which finding does the nurse expect to note during assessment?

Bounding, full peripheral pulses

A nurse reviews the results of a total serum calcium determination in a client with renal failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the nurse expect to note during assessment?

Bounding, full peripheral pulses

127 -A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? A. "When was your last menstrual period?" B. "When was your last bowel movement?" C. "Are you having any difficulty hearing?" D. "Are you having any difficulty breathing?"

C. "Are you having any difficulty hearing?"

27 A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? A. "Do you chew tobacco?" B. "Do you smoke cigarettes?" C. "Have you ever worked in a mine?" D. "Are you frequently exposed to paint products?"

C. "Have you ever worked in a mine?"

117 -A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? A. "Tell me your plan for saving the world." B. "Why do you think that you can accomplish this by yourself?" C. "I don't think anyone can save the world from the terrorists by himself." D. "You must be powerful. Do you really believe that you can do this by yourself?"

C. "I don't think anyone can save the world from the terrorists by himself."

2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A. "The test will take about 30 minutes." B. "I need to fast for 8 hours before the test." C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating."

C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

128 -A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? A. "It's important to rotate injection sites." B. "I need to store the insulin in a cool, dry place." C. "I need to keep any unopened bottles of insulin in the freezer." D. "I need to check the expiration date on the insulin before I use it."

C. "I need to keep any unopened bottles of insulin in the freezer."

31 A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? A. Insomnia B. Rigidity and akinesia C. Bilateral lung wheezes D. Orthostatic hypotension

C. Bilateral lung wheezes

61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? A. Coffee B. Broccoli C. Cheeseburger D. Chocolate milk

C. Cheeseburger

64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? A. Count the number of times that the infant swallows during a feeding B. Weigh the infant every day and check for a daily weight gain of 2 oz C. Count wet diapers to be sure that the infant is having at least six to 10 each day D. Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant

C. Count wet diapers to be sure that the infant is having at least six to 10 each day

38 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: A. Contact the physician B. Hold the next dose of imipramine C. Document the laboratory result in the client's record D. Have another blood sample drawn and ask the laboratory to recheck the imipramine level

C. Document the laboratory result in the client's record Correct

118- A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. A. Eat foods that are low in fat and protein B. Obtain pneumococcal and influenza vaccines C. Drink copious amounts of fluid and void frequently D. Avoid contact with any individual who has signs or symptoms of a cold E. Avoid contact with all individuals other than immediate family members

C. Drink copious amounts of fluid and void frequently Correct D. Avoid contact with any individual who has signs or symptoms of a cold Correct

86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is: A. Monitoring the client for signs of returning peristalsis B. Instructing the client in dietary changes to prevent constipation C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer Correct D. Encouraging the client to talk about the effects of the surgery on her femininity and sexual

C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer

63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? A. Diarrhea B. Vomiting C. Epistaxis D. Epigastric pain

C. Epistaxis

115 -A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? A. Perform the physical assessment B. Tell the client about the nursing unit rules C. Establish a trusting nurse-client relationship D. Tell the client that he or she will have to participate in self-care

C. Establish a trusting nurse-client relationship

53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? A. Nausea B. Bloody urine C. Hearing loss D. Electrocardiographic changes

C. Hearing loss

72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: A. Documenting the findings B. Encouraging the woman to walk C. Helping the woman empty her bladder Correct D. Massaging the fundus gently until it becomes firm

C. Helping the woman empty her bladder

129 -A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: A. Is a measure of the client's hematocrit level B. Is a measure of the client's hemoglobin level C. Helps predict the risk for the development of chronic complications of diabetes mellitus D. Provides a determination of short-term glycemic control in the client with diabetes mellitus

C. Helps predict the risk for the development of chronic complications of diabetes mellitus

119- A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that: A. Her hair will definitely fall out B. She should not be worrying about her hair at this point C. Her hair may fall out but will regrow after the chemotherapy is discontinued D. Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss

C. Her hair may fall out but will regrow after the chemotherapy is discontinued

96- A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? A. Providing pin care B. Medicating the client C. Notifying the physician Correct D. Removing some weight from the traction

C. Notifying the physician

111 -A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms? A. Agoraphobia B. Avoidant personality disorder C. Obsessive-compulsive disorder D. Dependent personality disorder

C. Obsessive-compulsive disorder

68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: A. No edema is present B. The client is dehydrated C. Pitting edema is present D. Blood is not pooling in the extremities

C. Pitting edema is present

45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. A. Bananas B. Potatoes C. Spinach D. Legumes E. Whole grains F. Milk products

C. Spinach Correct D. Legumes Correct E. Whole grains Correct

10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: A. Contact the physician B. Stop taking the medication C. Take the medication with food D. Take the medication twice a day instead of four times

C. Take the medication with food

21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: A. To always administer less insulin on the days of soccer games B. That it is best not to encourage the child to participate in sports activities C. That the child should eat a carbohydrate snack about a half-hour before each soccer game D. To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present

C. That the child should eat a carbohydrate snack about a half-hour before each soccer game

29 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client: A. To call his physician B. That he needs to drink more fluids C. That this is an occasional side effect of the medication D. That this may be a sign of developing toxicity of the medication

C. That this is an occasional side effect of the medication Correct

Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to:

Call the physician if a fever, sore throat, or muscle aches develop

A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:

Call the radiography department to obtain a chest x-ray

A nurse has assisted a health care provider in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:

Call the radiography department to obtain a chest x-ray Rationale: One major complication associated with central venous catheter placement is pneumothorax, which may result from accidental puncture of the lung. After the catheter has been placed but before it is used for infusions, its placement must be checked with an x-ray. Hanging the prescribed bag of PN and starting the infusion at the prescribed rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because they could result in the infusion of solution into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority.

An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication?

Cardiac monitor

An intravenous dose of adenosine is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication?

Cardiac monitor

The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?

Change in level of consciousness Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function.

A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should:

Check for the presence of a gag reflex

A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should:

Check for the presence of a gag reflex Rationale: In preparation for EGD, the client's throat is usually sprayed with an anesthetic to dampen the gag reflex and permit the introduction of the endoscope used to visualize the gastrointestinal structures. After EGD, the nurse places the highest priority on assessing the client for the return of the gag reflex. No food or oral fluids are given to the client until the gag reflex is fully intact.Vital signs are checked frequently, but this action is not associated with giving the client oral fluids. The client may be asked to use throat lozenges or a saline gargle to relieve a sore throat after the test, but neither action is related to giving the client oral fluids; additionally, neither action would be taken until the gag reflex had been detected again. Bowel sounds are not affected by this test.

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client

Check residual volume every four hours.

The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to:

Check the drainage for glucose

A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first:

Check the uterus and amount of lochia discharge

(Video) The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution?

Checking for gastric residual volume and assessing tube placement

The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution?

Checking for gastric residual volume and assessing tube placement

A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority?

Checking the client's blood pressure

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?

Checking the client's blood pressure

Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication?

Checking the client's blood pressure

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?

Checking the client's blood pressure Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions?

Cheeseburger

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions?

Cheeseburger Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness.

During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women?

Chlamydia. Chlamydia (B) is the most common and fastest spreading sexually transmitted infection (STI) in American women, with an estimated 3 million new cases each year. (A and D) are not as prevalent as Chlamydia. Although (C) can be spread by sexual intercourse, it is a common vaginal infection unrelated to sexual exposure.

A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next?

Clamping the intravenous catheter

A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet,low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement?

Confront the client about the consequences of the behavior. The nurse should provide a reality check by helping the client realize that there are consequences to his behavior (D). (A and B) do not help the client realize that his behavior is manipulative and harmful to himself as well as others. This behavior needs to be documented, but (C) does not need to be implemented.

A nurse preparing to administer digoxin to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.0 ng/mL (2.6 nmol/L). On the basis of this result, the nurse would:

Contact the health care provider

A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would:

Contact the physician

A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:

Contact the physician if the skin appears yellow

A school nurse observing a child diagnosed with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation?

Contacting the child's physician to report the findings

A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation?

Contacting the child's physician to report the findings

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action should be the nurse's priority?

Contacting the health care provider Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the health care provider. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not associated with the data in the question. Although the nurse would continue to monitor the client and the FHR and would document the findings, contacting the health care provider is the priority.

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority?

Contacting the physician

A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:

Contacting the physician

The nurse enters a client's room to complete discharge preparations and finds the client in tears

Continue the client's discharge process

A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with:

Conversion disorder

A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with:

Conversion disorder Rationale: It is most important to establish a trusting relationship, which will indicate to the client that the client is important. After a therapeutic relationship has been established, other interventions may be carried out. The nurse would perform a physical assessment, but this would not be the first intervention. The client should be informed of the nursing unit's rules, but, again, this is not the first intervention. Telling the client that he or she will have to participate in self-care is inappropriate. The client with bipolar disorder requiring hospitalization is likely to need assistance with care.

When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care?

Coordinating and educating about multidisciplinary services Clinical decisions to achieve client outcomes require collaborative efforts between the interdisciplinary team and the client-family cooperation. The nurse's role as collaborator of care is best displayed by coordinating and educating the client and family about multidisciplinary services (A). Information about financial assistance programs (B) is most often a role of social services. Although the nurse refers and consults with the healthcare team (C), client-focus care is best identified within a collaborative nurse-client-family relationship. Informing the client about a clinical diagnosis (D) is the responsibility of the healthcare provider.

11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? Type your answer in the space provided. Answer: ________mL

Correct Responses: "1670"

59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided. Answer ____mL

Correct Responses: "350"

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?

Count wet diapers to be sure that the infant is having at least six to 10 each day

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?

Count wet diapers to be sure that the infant is having at least six to 10 each day Rationale: The mother should be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally an infant should have at least 6 to 10 wet diapers (after the first 2 days of life) and at least 4 stools each day. The mother may also assess the swallowing and nutritive suckling of the infant, but this would not provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The mother is not usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0.5 to 1 oz) each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the mother's bottle-feeding technique.

76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

D) Aspiration for gastric contents The correct answer is A: Abdominal x-ray

90 - A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? SEE PIC A. B. C. D.

D.

107 A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? A. "Why are you saying that?" B. "Stop saying that. It's not true!" C. "You wouldn't like someone saying that to you. Would you?" D. "Don't say that. If you can't control yourself, we'll help you."

D. "Don't say that. If you can't control yourself, we'll help you."

57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? A. "I can resume sexual activity in 4 to 6 weeks." B. "I need to avoid straining when I have a bowel movement." C. "I should wear support hose for 6 months and elevate my legs frequently." D. "I need to contact my surgeon immediately if I feel any numbness in my genital area."

D. "I need to contact my surgeon immediately if I feel any numbness in my genital area."

120 -A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? A. "I can't drink alcohol." B. "I have to avoid having sex until the test for antibodies comes back negative." C. "I need to rest a lot during the day and get enough sleep at night." D. "I need to eat three meals a day with foods high in protein, fat, and carbs."

D. "I need to eat three meals a day with foods high in protein, fat, and carbs."

9 A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? A. "HIV is rarely an issue in rape victims." B. "Every rape victim is concerned about HIV." C. "You're more likely to get pregnant than to contract HIV." D. "Let's talk about the information that you need to determine your risk of contracting HIV."

D. "Let's talk about the information that you need to determine your risk of contracting HIV."

106 A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic? A. "Why don't you really want to attend?" B. "This is what your physician has prescribed for you as part of the treatment plan." C. "OK, let's have you attend music therapy. You can sing there. How does that sound?" D. "Perhaps you could attend and talk to the other clients and see what they're drawing and painting."

D. "Perhaps you could attend and talk to the other clients and see what they're drawing and painting."

123 - A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? A. 8 mm Hg B. 14 mm Hg C. 20 mm Hg D. 28 mm Hg

D. 28 mm Hg

55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred? A. A discoid uterus B. Sudden sharp vaginal pain C. Shortening of the umbilical cord D. A sudden gush of dark blood from the introitus

D. A sudden gush of dark blood from the introitus

125 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? A. Asking the child to describe the intensity of the pain B. Asking the child to use a numeric rating scale of 0 to 100 C. Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain D. Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain

D. Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain

46 A nurse caring for a client with pre-eclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? A. Vitamin K B. Protamine sulfate C. Potassium chloride D. Calcium gluconate

D. Calcium gluconate

124- An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note? A. A symmetrical smile B. Tightening of all facial muscles C. Ability to wrinkle the forehead on request D. Complaints of inability to close the eye on the affected side

D. Complaints of inability to close the eye on the affected side

41 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: A. Having the client perform a healthy coping behavior B. Having the client perform a ritualistic or compulsive behavior C. Providing a high degree of exposure of the client to the stimulus that the client finds undesirable D. Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening

D. Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening

110 -A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder? A. Neediness B. Perfectionism C. Preoccupation with details D. Hypersensitivity to negative evaluation

D. Hypersensitivity to negative evaluation

30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: A. Bradycardia B. Increased heart rate C. Decreased blood pressure D. Improved swallowing function

D. Improved swallowing function

85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: A. At any time after the surgery B. When menstruation resumes C. When pelvic sensation and response to stimuli return D. In about 6 weeks, when the vaginal vault is satisfactorily healed

D. In about 6 weeks, when the vaginal vault is satisfactorily healed

14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: A. Dry mouth B. Restlessness C. Feelings of depression D. Neck stiffness or soreness

D. Neck stiffness or soreness Correct

131 A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside? A. Bedside commode B. Suctioning equipment C. Electrocardiography machine D. Oxygen cannula and flowmeter

D. Oxygen cannula and flowmeter

97 -A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse A. Bivalve the cast B. Ask the physician to reapply the cast C. Use a nail file to smooth the rough edges D. Place small pieces of tape over the rough edges of the cast

D. Place small pieces of tape over the rough edges of the cast

76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? A. Checking the client's urine output B. Inserting an intravenous (IV) line C. Obtaining informed consent for a cesarean delivery D. Placing the client in a lateral position with the bed flat

D. Placing the client in a lateral position with the bed flat

112 -A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? A. Inflexible and rigid B. Self-sacrificing and submissive C. Highly critical of self and others D. Projecting blame, possibly becoming hostile

D. Projecting blame, possibly becoming hostile

77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? A. Pink lochia on postpartum day 4 B. White lochia on postpartum day 11 C. Bloody lochia on postpartum day 2 D. Reddish lochia on postpartum day 8

D. Reddish lochia on postpartum day 8

70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? A. Hysterectomy B. Insertion of an indwelling catheter C. Administration of oxytocin (Pitocin) D. Replacement of the uterus through the vagina into a normal position

D. Replacement of the uterus through the vagina into a normal position

33 A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: A. Corn B. Cocoa C. Peaches D. Sardines

D. Sardines

54 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? A. Painful vaginal bleeding B. Sustained tetanic contractions C. Complaints of abdominal pain D. Soft, relaxed, nontender uterus

D. Soft, relaxed, nontender uterus

100- A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to: A. Always perform the exercises while lying down B. Expect an improvement in the control of urine in about 1 week C. Tighten the pelvic muscles for as long as 5 minutes, three or four times a day D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10

D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10

66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: A. Milk B. Water C. Any meal D. Tomato juice

D. Tomato juice

16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? A. Fever B. Diarrhea C. Hypertension D. Tongue protrusion

D. Tongue protrusion

82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? A. Sodium 140 mEq/L B. Hemoglobin 12.5 g/dL C. Blood urea nitrogen (BUN) 20 mg/dL D. White blood cell count of 2500 cells/mm3

D. White blood cell count of 2500 cells/mm3

130- A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record? A. Writing that the client is very agitated B. Writing that the client yelled at the nurse C. Writing that the client is able to perform her own care D. Writing down the client's words and placing them in quotation marks

D. Writing down the client's words and placing them in quotation marks

A client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:

Decrease Rationale: Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect.

The healthcare provider prescribes digital evacuation

Decrease risk for bradycardia

The nurse is preparing to admister atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain th reason for the prescribed medication. What response is best for the nurse to provide?

Decrease the risk of bradycardia during surgery Atropine may be prescribed preoperatively to increase the automaticity of the sinoatrial node and prevent a dangerous reduction in heart rate (B) during surgical anesthesia. (A, C and D) do not address the therapeutic action of atropine use perioperatively.

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?

Decreased fluid volume

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?

Decreased fluid volume Rationale: Sickle cell disease is a genetic disorder that is manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, including interruption of blood flow to the respiratory system and placenta. Decreased fluid volume is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific symptoms at the time.

A client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect?

Decreases inflammation and pain

Which approach should the nurse use when preparing a toddler for a procedure?

Demonstrate the procedure using a doll. Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a procedure on a doll (A) enables a non-threatening, dramatic experience that can help prepare the toddler for the actual procedure. The primary developmental task in toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended, not (B). Since the toddler's attention span is short, teaching sessions should be brief (C) and can be repeated for reinforcement. Showing the equipment before its use helps relieve anxiety, but the child should be allowed to handle some of the equipment (D) to prevent frustration and alleviate fear.

A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement?

Demonstrate the wound care procedure to the PN while the PN assists It is within the PN's scope of practice to perform sterile wound care. The best learning of skills is through demonstration and return demonstration, therefore (D) promotes safe practice while allowing the PN the best opportunity to learn. (A) does not allow the PN to gain the experience needed to perform her role. (B) does not provide the best learning opportunity for the PN, or ensure safe practice. While (C) would provide a safe method for learning the wet-to-dry procedure, it doesn't address the problem immediately and is a more costly way for the PN to learn.

A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?

Denial related to the loss of a loved one. Based on the data provided, (C) is the best nursing diagnosis. This client is exhibiting symptoms of anxiety and the pain is too great for her to acknowledge, so she is denying the situation. Although she may seem confused (A), she is actually trying to deal with the pain through the defense mechanism of denial. (B) occurs after one year or longer following the loss. The client's husband died one month ago. (D) and depression are often related, and depression is sometimes described as unexpressed anger. However, this client has not acknowledged her loss (denial) and the anger is not yet realized.

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of:

Depression

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride . On the basis of this information, the nurse determines that the client most likely has a history of:

Depression Rationale: Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication.

Which assessment finding should make the nurse suspect that a 21 year old male client is taking anabolic steroids

Describes working hard to develop muscles Anabolic steroids, exogenous androgens, increase muscle mass (C). (A) is an adverse effect that occurs with females that are taking anabolic steroids, but not in males. Acne (B) is a potential side effect of anabolic steroids, but it is such a common occurrence in young males that it should not be the main indication of steroid use. A 10-pound weight gain (D) does not mean the young man is using steroids unless the weight gain is due to increased muscle mass.

A nurse in a health care provider's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem?

Distorted body image

A nurse in a physician's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem?

Distorted body image

A nurse in a health care provider's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:

Document the findings Rationale: Involution is the progressive descent of the uterus into the pelvic cavity after delivery. Twenty-four hours after birth, descent of the fundus begins at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Asking the health care provider to see the client immediately, having another nurse check for the uterine fundus, and placing the client in the supine position for 5 minutes and rechecking the abdomen are all incorrect and unnecessary actions in light of the assessment finding.

A client who is taking lithium carbonate complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:

Document the findings Rationale: Lithium carbonate is a mood stabilizer that is used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea, and therefore the nurse would simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the health care provider, instituting seizure precautions, and having a specimen drawn immediately for a serum lithium determination are all unnecessary. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs of toxicity and if these occur the health care provider needs to be notified.

A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:

Document the findings Rationale: The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present, hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes should be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes (3+ to 4+) suggest preeclampsia and must be reported to the health care provider. It is not necessary to contact the health care provider, because the finding is normal. Likewise, rechecking the client's reflexes after ambulation and performing active and passive ROM exercises incorrect and unnecessary actions.

The blood serum level of imipramine is determined in a client who is being treated for depression. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:

Document the laboratory result in the client's record Rationale: Imipramine is a tricyclic antidepressant that is often used to treat depression. The therapeutic blood serum level is between 225 and 300 ng/mL, so the nurse would simply document the laboratory result in the client's record. Asking the laboratory to recheck the level and withholding the next dose of the imipramine and contacting the health care provider are unnecessary.

A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation?

Documenting the finding

A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which action should the nurse take as a result of this observation?

Documenting the finding Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal movement. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother's vital signs are all unnecessary actions.

A low potassium diet is prescribed for a client what foods should the nurse try to avodi?

Dried prunes A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet.

A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply.

Drinking 2 to 3 L of fluid each day Resting and immobilizing the affected area

the nursie is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30pm. Which client response should the nurse document that indicates a successful outcome?

Drinks 240 mL of fluid five times during the shift. The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake.

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply.

Drooling Excessive oral secretions

Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?

Drowsiness

Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client?

Drowsiness

Cyclobenzaprine is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client?

Drowsiness

Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?

Drowsiness Rationale: Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication.

A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that:

Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts

What assessment finding should the nurse identify in a client with fluid volume excess?

Elevated blood pressure

Which family centered care concepts should the nurse encourage family members to promote child

Enabling and empowerment

The nurse identifies the nursing diagnosis of visual sensory/perceptual alterations

Encourage compliance with drug therapy to prevent loss of vision.

A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately:

Encourage the child to drink water or milk in small amounts

Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?

Encourage the use of an incentive spirometer. The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation (PaC02 > 45). The client needs to be encouraged in activities that increase the depth of breathing (e. g., use of the incentive spirometer) (B). (A) will only increase an already adequate Pa02. These are not crisis blood gas findings (C). (D) will only worsen the hypoventilation.

Which interventions should the nurse use when interacting with a client with Alzheimer's...

Encourage verbal and nonverbal communication Maintain a calm demeanor during all interactions

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:

Encouraging the client to deep-breathe, cough, and use an incentive spirometer

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:

Encouraging the client to deep-breathe, cough, and use an incentive spirometer Rationale: Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs of returning peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the effects of her surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer.

A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which of the following findings does the nurse expect to see documented in the child's record?

Episodes of cramping abdominal pain and excessive flatus

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client?

Epistaxis Rationale: Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism (i.e., conversion of plasminogen to plasmin, which destroys the fibrin in the blood clot). The thrombus, or blood clot, disintegrates when a thrombolytic medication is administered within 4 hours of an AMI. Necrosis resulting from blockage of the artery is prevented or minimized, and hospitalization may be shortened. Bleeding, a major adverse effect of thrombolytic therapy, may be superficial or internal and may be spontaneous. Epigastric pain, vomiting, and diarrhea are not adverse effects of this therapy.

After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatiod arthritis returns to the clinic for a follow up visit. Which laboratory finding should the nurse review for a therapeutic response?

Erythrocyte sedimentation rate. An elevated erythrocyte sedimentation rate (ESR) is indicative of active inflammation, so the nurse should determine if the ESR has normalized (D). Although corticosteroids influence glucose metabolism, an elevation in (A) may indicate a side-effect response to exogenous corticosteroids, not a desired effect. (B and C) do not indicate a therapeutic response to the corticosteroid therapy.

A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?

Establish a trusting nurse-client relationship

A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?

Establish a trusting nurse-client relationship Rationale: It is most important to establish a trusting relationship, which will indicate to the client that the client is important. After a therapeutic relationship has been established, other interventions may be carried out. The nurse would perform a physical assessment, but this would not be the first intervention. The client should be informed of the nursing unit's rules, but, again, this is not the first intervention. Telling the client that he or she will have to participate in self-care is inappropriate. The client with bipolar disorder requiring hospitalization is likely to need assistance with care.

Which intervention demonstrates the nurse's accountability...

Evaluating a client's outcomes after implementation of care.

A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as:

Fear Rationale: Fear is a response to a threat that is consciously recognized as a danger. In this situation, the client's reaction is one of fear, and the client verbalizes the object of fear (dying). There is no evidence of denial, acceptance, or preoccupation with self in the client's statement.

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client?

Fever

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin . Which finding, indicating an adverse reaction to the medication, does the nurse monitor the client?

Fever Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication.

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply.

Fever Vasculitis Abdominal pain

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement?

Firmly inform the client that acting out anger is not acceptable.

A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide?

Five to seven days after menses cease. Due to the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is 5 to 7 days after menstruation stops (D) because physiologic alterations in breast size and activity reach their minimal level after menses. (A and B) can vary from month to month and do not provide a consistent day of the month for the client to remember to do BSE. (C) is commonly the day of the menstrual cycle that the breast are most affected by hormonal influence.

A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?

Fowler's position

The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?

Frequent blood pressure checks, including readings taken automated machines are recommended Frequent blood pressure checks (D) are recommended for hypertensive clients to evaluate the effectiveness of treatment. Symptoms such as (A) are not typical of essential hypertension, which is an asymptomatic disease. Treatment (B) usually includes dietary modifications and exercise, which should not be discontinued when medications are added to the treatment plan. While the RN is ultimately responsible for the assessment of blood pressures (C), caregivers are not restricted from obtaining the blood pressure readings.

Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?

Give one hour before or two hours after a meal When administering a drug on an empty stomach, the drug should be given either one hour before a meal or two hours after a meal (B), which is the average transit time from the stomach to the duodenum after eating. An eight-hour fast is more time than is needed for the stomach to empty (C) and is not necessary. The last time any food or drink has been ingested is a better indicator of an empty stomach, rather than after the client has missed a meal (C). Some liquids, such as grapefruit juice, can alter the drug's dilution and absorption (D).

A female client arrives at the clinic because her boyfriend....

Gonorrhea is often asymptomatic in women because the infection is not visible.

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:

Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:

Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Rationale: The technique of systematic desensitization involves gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening with the goal of defusing the phobia. Having the client perform a healthy coping behavior is the description of modeling. Performing ritualistic or compulsive behaviors is a behavior characteristic of clients with obsessive-compulsive disorder. Having the client perform a ritualistic or compulsive behavior may not be therapeutic; additionally, it is not associated with systematic desensitization. Providing a high degree of exposure to a stimulus that the client finds undesirable is the technique known as flooding.

The nurse is assessing a client who complains of weight loss, racing heart rate and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retrace, and a staring expression. These findings are consistent with which disorder?

Graves disease This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with these symptoms.

Which change in sleep patterns is most likely to occur in an older adult?

Has a decline in stage 4 sleep

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate (DDAVP) by way of the nasal route. For which of the following occurrences does the nurse tell the client to contact the physician?

Headache and nausea

A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client?

Hearing loss

A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client?

Hearing loss Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity.

A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be:

Helping the woman empty her bladder

A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be:

Helping the woman empty her bladder Rationale: In the postpartum period, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is found to be higher than the expected level or shifted from the midline position (usually to the right), the bladder may be distended. The location of the fundus should be rechecked after the woman has emptied her bladder. If the fundus is difficult to locate or is boggy (soft), the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Encouraging the woman to walk is inappropriate at this time. The nurse would document fundal position, consistency, and height and any other interventions taken (e.g., uterine massage) after the woman has emptied her bladder.

A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that:

Her hair may fall out but will regrow after the chemotherapy is discontinued

A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:

Herbs and spices

A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:

Herbs and spices Rationale: Most clients with CKD retain sodium. The client with CKD is instructed not to add salt at the table or during food preparation. Herbs and spices may be used as an alternative to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit potassium intake. The client is also instructed to avoid salt substitutes, many of which are composed of potassium chloride, if oliguria is present. Processed foods are discouraged because they are high in sodium.

A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid?

High-impact exercise

A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which type of exercise does the nurse tell the client to avoid?

High-impact exercise

The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?

History of inflammatory bowel disorders Enemas should be avoided or administered with extreme caution to clients with inflammatory bowel disorders, so obtaining this historical information has the highest priority (A). (B and C) also provide valuable information, but are not of the same priority as (A). (D) is not necessary prior to enema administration.

A male client with degenerative arthritis of the knees and hips takes an OTC NSAID for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get sleep, I find that I wake up a number of times during the night." Which info should the nurse obtain first?

How intense does the client rate his pain on a scale of 1 to 10?

A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

How long has the client been taking the medication Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication (A) provides information to direct additional instruction. (B, C, and D) are not relevant.

A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.

Hunger Weakness Blurred vision

A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which behavior is a characteristic of the disorder?

Hypersensitivity to negative evaluation Rationale: Avoidant personality disorder is a psychiatric condition in which a person feels extremely shy, inadequate, and sensitive to rejection. Other characteristics of avoidant personality disorder include excessive anxiety in social situations and hypersensitivity to negative evaluation. Neediness is a characteristic of dependent personality disorder. Perfectionism and preoccupation with details are characteristics of obsessive-compulsive disorder.

A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?

Hypotension, rapid weak pulse, and rapid respiratory rate The clinical manifestations of Addisonian crisis are often the manifestations of shock (C); the client is at risk for circulatory collapse and shock. (A) indicates clinical manifestations of Cushing's syndrome, (B) of pheochromocytoma (tumor of adrenal medulla), and (D) of thyroid storm (thyrotoxic crisis).

The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement?

Immunizations that decrease occurrences of many contagious diseases Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life, such as immunization (A). Health screenings (B and C) are the mainstay of secondary prevention and include interventions designed to increase the probability that disease is diagnosed early when treatment is likely to result in cure. Tertiary prevention (D) includes interventions aimed at disability limitation from disease, injury, or disability.

A mother brings her 4 year old boy to the clinic because he spends his day in constant motion, talks excessively, and is easily distracted from playing with his toys. His preschool teacher is unable to keep him focused in the classroom and suggested he undergo a mental health evaluation. Which nursing diagnosis should the nurse formulate?

Impaired social interaction

which nursing intervention is an example of a competent preformance criterion for an occupational and environmental health nurse?

Implements health programs for construction workers Implementing health programs for construction workers (B) is an example of a competent performance criterion in management, which includes monitoring of the quality and effectiveness of vendor services. (A) is an example of an expert performance criterion for case management. (C and D) are examples of a proficient performance criteria for management.

A client with myasthenia gravis is taking neostigmine bromide. The nurse determines that the client is gaining a therapeutic effect from the medication after noting:

Improved swallowing function Rationale: Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs of an adverse reaction to the medication.

A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes:

In a vertical position with the needles pointing up

A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:

In about 6 weeks, when the vaginal vault is satisfactorily healed

A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:

In about 6 weeks, when the vaginal vault is satisfactorily healed Rationale: After abdominal hysterectomy, the client is instructed to avoid sexual intercourse until the vaginal vault is satisfactorily healed. This takes about 6 weeks. A woman who has undergone this procedure must adjust to changes in the nature of pelvic sensations and stimuli during sexual intercourse; however, this is not related to when sexual intercourse may be resumed. The client will not have menstrual periods after abdominal hysterectomy.

The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. which interventions should the nurse include in the teaching plan

Incorporate favorite foods into the adolescent's diet.

28 A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. Answer: _____mL

Incorrect Correct Responses: "1, .625, 0.625"

Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsycotioc medication?

Increase daily intake of raw fruits and veggies A common side effect of antipsychotic medications is constipation, and increasing high-fiber foods in the diet (A) can help to alleviate this problem. (B and C) have no particular effect on possible side effects from taking antipsychotic medications. While some antipsychotic medications cause urinary retention, which should be reported to the healthcare provider, urine output increase (D) is likely to occur if additional fluids are consumed to overcome a dry mouth, which is a common side effect of antipsychotic medications.

A laxative has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to:

Increase fluid intake

Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to:

Increase fluid intake

Laboratory studies are performed on a client diagnosed with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease?

Increased white blood cell (WBC) count

Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease?

Increased white blood cell (WBC) count

The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?

Individual beliefs The client's beliefs (C) are key to accepting healthcare practices and interventions. Although (A, B, and D) influence an individual's interpretation and acceptance of different healthcare practices, (C) is most influential.

Which infant is at risk for Rh incompatibility?

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis?

Initiate a smoking cessation program.

Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while taking the medication?

Intake and output

The nurse is evaluating a client's response to diuretic therapy

Intake, output, and daily weight

What information in a client's history indicates the highest risk factor for hepatitis C?

Intravenous drug abuse

A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4 hours, the nurse determines the client has no drainage from the NGT and has absent bowel sounds. What action should the nurse implement?

Irrigate the NGT with normal saline.

A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client:

Is at low risk for AIDS

A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?

It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state. This is a legal document that allows individuals to identify someone to make decisions for health care, identifies how aggressive treatment should be if the client should ever be in a coma or persistent vegetative state, and lists any medical treatments they would never want performed (B). (A) is the definition of the "Living Will"; some states and Canada do not consider Living Wills legal documents. A durable power of attorney is a legal document (C), and it is not a hospital form (D).

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2017. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is:

July 2, 2018 Rationale: Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. To calculate the EDD with the use of this rule, the nurse would subtract 3 months from the date of the first day of her LMP, add 7 days, and then adjust the year. First day of the LMP, September 25, 2017; subtract 3 months, June 25, 2017; add 7 days, July 2, 2017; add 1 year, July 2, 2018.

A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take?

Keep the client in bed in the supine position A common postoperative complication after valve replacement is arterial occlusion from a clot, which requires anticoagulant therapy to prevent further enlargement of the thrombus and reduce the risk of embolization. Recently formed thrombi can also be effectively treated with an intraarterial infusion of a thrombolytic agent, followed by bed rest (C) and periodic angiography to monitor the dissolution of the clot. (A, B, and D) are contraindicated due to the risk of vascular occlusion and embolization.

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply.

Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair.

A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information?

Lack of adequate diversional activity

A pediatric nurse is caring for a hospitalized toddler. Which of the following activities does the nurse deem the most appropriate for the toddler?

Large building blocks

Which FHR finding should the nurse report to the HCP immediately?

Late decelerations

Which finding should the nurse idnetify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?

Lethargy or irritability Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability (C). Without treatment, progressive signs of neurologic damage include (A, B, and D).

A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which of the following findings indicates to the nurse that fluid replacement is inadequate?

Level of consciousness remains unchanged

A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic nonketotic syndrome (HNS). Which finding indicates to the nurse that fluid replacement is inadequate?

Level of consciousness remains unchanged

Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the health care provider's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the health care provider to confirm the prescription for warfarin sodium because:

Levothyroxine amplifies the effect of warfarin sodium

Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because:

Levothyroxine amplifies the effect of warfarin sodium

A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to:

Lie down to administer the subcutaneous injection

A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium at home. The nurse teaches the client about the medication and tells the client to:

Lie down to administer the subcutaneous injection

Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of?

Lightheadedness

A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?

Liver. Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver (A) function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as n onsteroidal anti-inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place the client at risk for toxic reactions related to (C or D).

A male client who lives in an area endemic with lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?

Look for early signs of lesion that increases in size with a red border, clear center. The client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center (B) at the site of the tick bite. A tick should be removed with tweezers by pulling straight from its insertion away from the skin, and not compressing its body or covering it with oil (A). Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is transmitted by the bite of an infected deer tick, and antiviral agents (D) are ineffective. Symptoms, such as fever, chills, headache, stiff neck, fatigue, and swollen lymph nodes are more typical, not nausea and vomiting (C).

During admission to the mental health unit, a female client with bipolar disorder...

Maintain an environment that reduces stimulation of the client.

A patient returns from surgery following an abdominal-perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. On the first postoperative day, the nurse gives the highest priority to a. teaching about a low-residue diet. b. monitoring drainage from the stoma. c. assessing the perineal drainage and incision. d. encouraging acceptance of the colostomy site.

Maintain dry perineal dressings C Assessing the perineal drainage and incision

A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?

Maintaining cuff pressure

A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Wterm-67hich intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?

Maintaining cuff pressure Rationale: Necrosis of the tracheal wall caused by the cuff of an endotracheal tube can lead to the development of an opening between the posterior trachea and esophagus, a complication known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the health care provider. Suctioning should be performed only as needed; frequent suctioning can cause mucosal damage. Maintenance of mechanical ventilation settings ensures that the client is adequately oxygenated, but this intervention is not a measure for the prevention of tracheoesophageal fistula. Alternating the use of a cuffed tube and a cuffless tube on a daily basis is incorrect, because the endotracheal tube would not be removed and replaced on a daily basis.

The nurse identifies bright-red drainage about 6 cam in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next??

Mark the drainage on the dressing and take vital signs Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the 6 cm drainage on the dressing (A) assists in determining an increase in the amount which is supported with any changes in vital signs that indicates possible internal bleeding. (B) is premature. Removing the initial dressing may disturb the surgical site and increase the risk of hemorrhage and infection (C). (D) is compared with the previous amount of drainage marked on the dressing, so (A) is necessary.

A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma?

Metoprolol Tartrate( Lopressor) The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders.

A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the health care provider suspects iron-deficiency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results?

Microcytic red blood cells (RBCs)

A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the physician suspects iron-deficiency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results?

Microcytic red blood cells (RBCs)

A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice?

Mucous membranes

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?

Multiple sexual partners

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?

Multiple sexual partners Rationale: Risk factors for cervical cancer include multiple sexual partners, a history of human papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical cancer.

Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences:

Neck stiffness or soreness

Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the health care provider immediately if she experiences:

Neck stiffness or soreness Rationale: Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness, which could be the first signs of a hypertensive crisis. Dry mouth and restlessness are common side effects of the medication.

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

Notifies the emergency department physician

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to a. notify the patient's health care provider. b. check the patient's blood pressure. c. assess the external fixator pins for redness or drainage. d. elevate the extremity and apply ice over the wound site.

Notify the HCP

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement?

Notify the healthcare provider.

A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which action should the nurse take next?

Notifying the healthcare provider Rationale: A client in traction who complains of severe pain may require realignment or may have traction weights that are too heavy. The nurse realigns the client and, if this is ineffective in relieving the pain, notifies the health care provider. Severe leg pain, once traction has been established, indicates a problem. Provision of pin care is not related to the problem as described. The client should be medicated after an attempt has been made to determine and treat the cause; the cause of the severe pain should be investigated first. The nurse should never remove the weights from the traction without a specific prescription to do so.

A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next?

Notifying the physician

A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was febuary 14. the client wants to know the expected date of birth (EDB) how should the nurse respond?

November 21 Subract 3 months and add 7 days to the first day of the last normal menstrual period. Using Nägele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period. The client's LMP is February 14, so less 3 months + 7 days is November 21 (B) of the next year. (A, C, and D) are inaccurate.

Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication?

Numbness and tingling of the fingers or toes

Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the client to report to the health care provider if she experiences them while taking the medication?

Numbness and tingling of the fingers or toes Rationale: Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce ergotamine poisoning (ergotism). Symptoms include nausea, vomiting, weakness in the legs, pain in the limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these symptoms to the health care provider if they occur. Cough, fatigue, lethargy, and dizziness are side effects not adverse effects of the medication.

Which action should the nurse implement to assess for JVD in a client with HF?

Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

A female client reports to the nurse that her sleep was interrupted by " thoughts of anger towards my husband" What type of thoughts is the client having?

Obsessive Obsessive thoughts (A) are thoughts that the client is unable to control. (B) are irrational fears. (C) are false beliefs. (D) are suspicious thoughts

A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms?

Obsessive-compulsive disorder

A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. Which anxiety disorder does the nurse associate this client's symptoms?

Obsessive-compulsive disorder Rationale: Obsessive-compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing anxiety; or by a combination of such thoughts (obsessions) and behaviors (compulsions). The client is inflexible and rigid, and is highly critical of self and others. The characteristics of dependent personality disorder include neediness and self-sacrificing and submissive behaviors. The client with avoidant personality disorder is extremely shy, feels inadequate, and is sensitive to rejection. Agoraphobia is the fear of open spaces.

A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?

Obtain the permission of the custodial parent for the surgery. The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form (D).

The nurse is providing comfort and palliative care for a terminally ill client

Offer high-protein foods

A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?

Offering high-calorie and high-protein foods and fluids frequently throughout the day

A client diagnosed with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?

Offering high-calorie and high-protein foods and fluids frequently throughout the day Rationale: The client should be offered high-calorie and high-protein foods and fluids frequently throughout the day. Small, frequent snacks are more easily tolerated than large plates of food when the client is anorexic. The client should be offered choices of foods and fluids he or she likes, because the client is more likely to consume foods he or she has selected. The client should be weighed weekly, not daily. Weight gain may not be noted daily, which may cause the client to view the interventions to improve nutritional status as useless.

A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's:

Physical and functional abilities

A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the health care provider's instructions, understanding that the gait was selected after assessment of the client's:

Physical and functional abilities Rationale: A crutch gait is selected after an assessment of the client's physical and functional abilities and the disease or injury that resulted in the need for crutches. Assessing the client's uneasiness about using crutches, feelings about being mobility restricted, and understanding of the need for increased mobility are also important considerations, but assessment of the client's physical and functional abilities is most important in ensuring safety in ambulation.

A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast?

Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French.

A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:

Pitting edema is present

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse

Place small pieces of tape over the rough edges of the cast

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse

Place small pieces of tape over the rough edges of the cast Rationale: If a client with a cast experiences skin irritation from the edges of the cast, the nurse should petal (place small pieces of tape over) the rough edges of the cast to minimize the irritation. Bivalving is performed if the limb swells occurs and the cast becomes too tight. Using a nail file to smooth the rough edges could cause pieces of the cast to fall into the cast, possibly resulting in the disruption of skin integrity. It is not necessary to contact the health care provider, and there is no reason to reapply the cast.

The wife of a client diagnosed with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL (3.3 mmol/L) and that her husband is awake but groggy. The nurse tells the client's wife to immediately:

Place some honey in her husband's mouth, between his gums and cheek

The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately:

Place some honey in her husband's mouth, between his gums and cheek

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock?

Placing the client in a lateral position with the bed flat

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the health care provider, which does the nurse specify as the first action in the event of shock?

Placing the client in a lateral position with the bed flat Rationale: If the client exhibits signs of hypovolemic shock, the nurse would contact the health care provider. The nurse would monitor fetal status closely and take action to minimize the effects of hypovolemic shock and promote tissue oxygenation. The client would be placed in a lateral position, with the head of the bed flat to increase cardiac return and thus increase circulation and oxygenation of the placenta and other vital organs. After positioning the client, the nurse would insert IV lines in accordance with the health care provider's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this is not the first action.

A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client?

Pleuritic chest pain

The nurse identifies a break in sterile technique...

Point out the observation immediately to the surgical team.

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?

Positive result on d-dimer study

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?

Positive result on d-dimer study Rationale: DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased. The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.

A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?

Powerlessness

A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?

Powerlessness Rationale: Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives his or her own body image.

A nurse is transcribing a health care provider's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the health care provider to ask about the prescription because:

Prednisone can increase the blood glucose level

A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the physician to ask about the prescription because:

Prednisone can increase the blood glucose level

Lasix 20 mg PO is prescirbed for a client at 0600. the medication is available in a sound tablet of 40 mg. Before breaking the tablet, what action should the nurse take?

Preform hand hygiene Before breaking a scored tablet, the nurse should perform hand hygiene (B) to ensure medical asepsis. (A and C) are unnecessary. The nurse should administer the medication before charting (D).

A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care?

Projecting blame, possibly becoming hostile

A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care?

Projecting blame, possibly becoming hostile Rationale: A client with paranoid personality disorder projects blame, is suspicious of others, and may become hostile or violent. The client also experiences cognitive or perceptual distortions. A client who is inflexible and rigid and is highly critical of self and others is showing signs of obsessive-compulsive disorder. Being self-sacrificing and submissive is a characteristic of a client with dependent personality disorder.

A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred?

Protamine sulfate

A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?

Provide antiinflammatory response Nonsteroidal antiinflammatory drugs (NSAIDs) have antiinflammatory properties (B), which relieves pain associated with osteoarthritis and differs from acetaminophen, a non-narcotic analgesic and antipyretic. (A) does not teach the client about the medication's actions. Although NSAIDs are irritating to the gastrointestinal (GI) system and can cause GI bleeding (C), instructions to take with food in the stomach to manage this as an expected side effect should be included, but this does not answer the client's question. Acetaminophen is potentially hepatotoxic (D), not NSAIDs.

A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. The nurse plans to first:

Provide the client with 100% oxygen by mask

The neonatologist requests a mother to provide breast milk for her 32 week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the brest milk. Which additional information should the nurse include to ensure the mother understands the request?

Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients.

The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

Ptosis on the left eyelid Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by rapid, rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs with hyperthyroidism.

To locate the point of maximum impulse (PMI) of a client's heart, the nurse's hand (fingertips) should be placed over which location? 1. A 2. B 3. C 4. D

QUESTION - Where do you find the PMI? STRATEGY - Picture the anatomy of the heart and its position in the body. NEEDED INFO - PMI: forward thrust of left ventricle during systole produces normal pulsation on chest wall. Indicates size and position of heart. Should be felt in 5th intercostal space. If apical impulse appears in more than one intercostal space, may indicate ventricular enlargement. CORRECT ANSWER - (3) The fifth intercostal space at the midclavicular line. (1) Wrong position. (2) Wrong position. (4) Incorrect.

The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?

Question the type and quantity of foods eaten in a typical day. The child is overweight for height, so assessment of the child's daily diet (C) should be determined. The child does not need (A or B), both of which will increase the child's weight. Poor nutrition (D) is commonly seen in underweight children, not overweight.

A client diagnosed with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first:

Raise the head of the client's bed

A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first:

Raise the head of the client's bed

A 32-year-old male client is admitted with paranoid schizophrenia

Reassure the client that he is safe and should rest.

the nurse is preparing a client for schedules surgical procedure. What client statement should the nurse report to the healthcare provider.?

Recalls drinking a glass of juice after midnight. Because there is a risk of aspiration while under general anesthesia The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications.

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT?

Recent stroke

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the health care provider who is scheduled to perform the ECT?

Recent stroke Rationale: Several conditions pose risks in the client scheduled for ECT. Among them are recent myocardial infarction or stroke and cerebrovascular malformations or intracranial lesions. Hypothyroidism, glaucoma, and peripheral vascular disease are not contraindications to this treatment.

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:

Recheck the temperature in 4 hours

What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies?

Recognizes the value of a client's input into their own health care. Alternative and complementary therapies offer human-centered care based on philosophies that recognize the value of the client's input and honor cultural and individual beliefs, values, and desires (C). These therapies do not subscribe to (A) which is the primary focus of traditional Western medicine. Alternative therapies are a part of an integrative approach to health care, not (B). An increasing number of Americans (D) are using alternative and complementary therapies as options to traditional Western modalities.

A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?

Reddish lochia on postpartum day 8

A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the health care provider?

Reddish lochia on postpartum day 8 Rationale: Lochia is the postdelivery vaginal discharge from the uterus consisting of blood from the vessels of the placental site and debris from the deciduas. Rubra is the bright-red lochial discharge that appears from delivery day to day 3. Serosa is the brownish-pink lochial discharge that appears on days 4 to 10. Alba is the white lochial discharge that appears on days 10 to 14. Reddish lochia on postpartum day 8 is an abnormal finding and would be reported to the health care provider.

The nurse is instructing a client about the use of podofilox...

Redness, peeling, and itching may occur at the site of application.

While being seen by a health care provider, a client reports persistent fever, malaise, and night sweats. On physical examination, the health care provider palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies?

Reed-Sternberg cells on biopsy of a lymph node

While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies?

Reed-Sternberg cells on biopsy of a lymph node

A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration?

Regular (Humulin R)

During the physical assessment, which finding should the nurse recognize as a normal finding?

Regular pulsation at the epigastric area when the client is supine. Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment.

An older Chinese client refuses to perform...

Reliance on family members to assist with care.

The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client?

Relief of anxiety

A mother asks the nurse to explain how using time-out

Removes a reinforcer that a child is receiving

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?

Replacement of the uterus through the vagina into a normal position

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?

Replacement of the uterus through the vagina into a normal position Rationale: If uterine inversion is suspected, the nurse immediately prepares the client for replacement of the uterus through the vagina. If this is not possible or effective, laparotomy with replacement is performed. Hysterectomy may be required. Intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia is usually needed to relax the uterus enough to replace it. Once the uterus has been replaced and the placenta removed, oxytocin is given to induce uterine contraction and control blood loss. To help prevent trapping of the inverted fundus in the cervix, oxytocin is not given until the uterus has been repositioned. An indwelling catheter is often inserted to aid monitoring of fluid balance and keep the bladder empty so that the uterus can contract fully, but this is not the action that would be taken immediately.

A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take?

Report the incident to the immediate supervisor Even if the drugs were not narcotics, it is the nurse-manager's responsibility to report these findings to the person in charge of the unit (B). (A) puts the colleague on guard and promotes denial and defensiveness. (C) is ignoring the event, which could enable the behavior to continue. (D) promotes "gossip" about the colleague and is not be helpful to the colleague or to the unit.

The nurse is providing care for a 6-year-old boy who has a broken arm and multiple bruises

Report the situation to appropriate authorities

A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of:

Respiratory alkalosis

A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of:

Respiratory alkalosis (uncompensated)

A client who begins an exercise program..

Rest and increased carbohydrate intake

43. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation

Review Information: The correct answer is B: Leukopenia

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:

Sardines Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Corn, cocoa, and peaches do not contain appreciable amounts of calcium.

A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

Secondary prevention Secondary prevention (B) attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that create a suspicion of battering and domestic violence. (A) would be activities that occur before the disease process begins, such as providing community seminars on the risks, and signs and symptoms of domestic violence. (C) occurs after the disease process has started, and includes referring the client to a battered women's shelter for treatment following unabated, chronic abuse. Health promotion can be incorporated in all levels of prevention (D).

A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for:

Seizure activity

A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note?

Serum bicarbonate of 12 mEq/L (12 mmol/L)

The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clincail picture ?

Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D).

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.

Spinach Legumes Whole grains

the nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with?

Spinal cord injury Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock.

An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?

Stage 3 Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.

A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?

Steak

Which therapeutic response should the nurse identify that best evaluates the use of reminiscence strategies with an older adult?

Stimulate memory chains through associations.

A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client?

Stokes sign

A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?

Stop the code immediately. A durable power of attorney documents the client's wishes and supersedes the wishes of the medical staff (A). (B) violates the client's rights. The code should be stopped (C). The family's support (D) is not relevant. The client's wishes are most important.

A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:

Stops the oxytocin infusion

A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:

Stops the oxytocin infusion Rationale: Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. It is used to induce or augment labor at or near term. The nurse monitors uterine activity for the establishment of an effective labor pattern and for complications associated with the use of the medication. If uterine hypertonicity or a nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen with the use of a snug face mask at 8 to 10 L/min. The nurse would also notify the health care provider. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion are not the immediate actions.

A primipara with a breech presentation is in the transition phase pf labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

Supine with the foot of the bed raised The supine position with the foot of the bed elevated (D) (Trendelenburg) is one position used to alleviate gravitational pressure by the fetus on the prolapsed umbilical cord, (A, B, and C) do not alleviate pressure on the umbilical cord.

A hospitalized client scheduled for surgery is told by the health care provider that she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she is refusing the transfusion. What is the most appropriate initial nursing action?

Supporting the client's decision to refuse the transfusion

A hospitalized client scheduled for surgery is told by the physician that she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she is refusing the transfusion. What is the most appropriate initial nursing action?

Supporting the client's decision to refuse the transfusion

The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis?

Swimming lessons in an indoor pool. External otitis is commonly caused by exposure to bacteria while swimming (C). In addition, chlorine tends to alter the normal flora of the external ear canal, increasing the risk for infection. Participation in (A, B, or D) may increase the child's risk for trauma, and families should be instructed to use protective equipment to reduce this risk.

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.

Tachycardia Diminished peripheral pulses

A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:

Take the client to the bathroom and provide her with a warm bath

A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:

Take the client to the bathroom and provide her with a warm bath Rationale: For the client with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize manic behavior. The nurse should encourage frequent rest periods during the day and keep the client in areas of low stimulation. At bedtime, the nurse should provide warm baths, soothing music, and medication when indicated. The client should not consume products containing caffeine. Staying with the client and observing her behavior, telling the client that it is time to go to sleep and to go to her room, and telling the client that other clients are trying to sleep and that she is being disruptive do not address the client's needs and are not measures that will help the client relax and sleep.

A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:

Take the medication with food Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse would not instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions are not within the legal scope of the role of the nurse. Contacting the health care provider is premature, because the client's complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food.

A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin (Lanoxin) 0.25 mg in the treatment of congestive heart failure (CHF). Which instructions should the nurse include on the list? Select all that apply.

Take your pulse before taking each dose. Take the digoxin at the same time each day. Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances.

During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?

Taking medication, with community follow-up The most important goal for discharge is for the client to take medications (A), which will stabilize her mood and promote an optimum level of functioning. (B, C, and D) are important goals, but first the client needs to be stabilized on her medication.

A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which measure does the nurse take in the care of the client?

Teaching the client to move the head from side to side (scan) when eating

A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which of the following measures does the nurse take in the care of the client?

Teaching the client to move the head from side to side (scan) when eating

When conducting an assessment interview with a new client, which question should the nurse use...

Tell me about your family.

An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation.

Tell the child to go to the gym to play basketball.

The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message , which nursing action is best for the nurse to take?

Tell the receptionist to have the healthcare provider return the phone call. The best nursing action is to ask for a return call from the healthcare provider (B) because the nurse must maintain the client's confidentiality. (A) is acceptable, but the best action is to leave a telephone number and request a return call. (C or D) do not promote confidentiality.

The nurse is assessing a postpartum client who delivered in the car...

Temperature of 100.8 F 24 hours after delivery.

A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:

Temporarily eases anxiety in the client

A client with multiple sclerosis has been started on baclofen (Lioresal) for muscle spasms. The client calls the physician's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client:

That drowsiness usually diminishes with continued therapy

A client with multiple sclerosis has been started on baclofen for muscle spasms. The client calls the health care provider's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client:

That drowsiness usually diminishes with continued therapy

A nurse is providing home care instructions to a client diagnosed with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client:

That ringing in the ears is a sign of toxicity

The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:

That the child should eat a carbohydrate snack about a half-hour before each soccer game

The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:

That the child should eat a carbohydrate snack about a half-hour before each soccer game Rationale: The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the health care provider. There is no reason for the child to avoid participating in sports.

Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:

That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol

Disulfiram is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:

That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol Rationale: Disulfiram is an alcohol abuse deterrent prescribed to motivated clients who have shown the ability to stay sober. Driving is not prohibited; however, the client is instructed to use caution when driving and performing other tasks that require alertness. The medication is taken daily (not just when the client has a desire to drink alcohol), and the effects of the medication last 5 days to 2 weeks after the last dose is taken. The medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol. Otherwise, an alcohol-disulfiram reaction will occur, with effects consisting of facial flushing, sweating, a throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting. This reaction may last 30 to 120 minutes.

A nurse is providing information about the storage of insulin to a client who will be self-administering regular insulin. The nurse tells the client:

That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity

A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client:

That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity

A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:

That this is an occasional side effect of the medication

A client undergoing therapy with Carbidopa/Levodopa calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:

That this is an occasional side effect of the medication Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause darkening of the urine or sweat. The client should be reassured that this is a harmless side effect of the medication and that the medication's use should be continued. Although fluid intake is important, telling the client that he needs to drink more fluid is incorrect and unnecessary. Telling the client that the darkening of his urine may signal developing medication toxicity is incorrect and might alarm the client unnecessarily. There is no need for the client to call the health care provider.

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond?

The chart is the property of the hospital but I will see that a copy is made for you. The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record (D) should be provided. The client does not lose his legal rights to his medical record if he leaves AMA (A). The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy (B). The hospital must maintain records of the care provided and should not release the original record (C).

A 5-year-old girl's sibling dies from sudden infant death syndrome. The parents are concerned because she showed more outward grief when her cat died than she is showing now. The nurse should explain that: A. this is suggestive of maladaptive coping and referral for counseling is needed. B. the child is not old enough to have a concept of death. C. the child is not old enough to have formed a significant attachment to her sibling. D. the death may be so painful and threatening that the child must deny it for now.

The child focuses on another connection because the sibling's death is misunderstood. D

A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which finding would be a matter of concern for the nurse as an indication of hypocalcemia?

The client complains of a tingling sensation around the mouth.

A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia?

The client complains of a tingling sensation around the mouth.

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?

The client reports a history of sexual abuse by her father

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?

The client reports a history of sexual abuse by her father. Rationale: Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality should be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment.

Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication?

The client takes a prescribed antihypertensive.

Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing health care provider before administering the medication?

The client takes a prescribed antihypertensive. Rationale: Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication.

A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated?

The client takes isosorbide dinitrate (Isordil)

After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?

The client who has a new onset of difficult breathing. Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A).

74. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

The correct answer is A: A 79 year-old malnourished client on bed rest

94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins

The correct answer is A: An infant who has been identified to have botulism

90. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity

The correct answer is A: Assess the severity and location of the pain

61. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance

The correct answer is A: Avoid chocolate and cheese

14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness

The correct answer is A: Can predispose to dysrhythmias

78. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

The correct answer is A: Exercise doing weight bearing activities

27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88

The correct answer is A: FHT 168 beats/min

49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube

The correct answer is A: Hold the tube feeding and notify the provider

63. The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts

The correct answer is A: Non-steroidal anti inflammatory drugs

41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Read just the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes

The correct answer is A: Notify the health care provider

83. A client with diarrhea should avoid which of the following? A) Orange juice B) Tuna C) Eggs D) Macaroni

The correct answer is A: Orange juice

70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

The correct answer is A: Orthostatic hypotension is a common side effect

29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

The correct answer is A: S3 ventricular gallop

10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right with the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

The correct answer is A: Side-lying on the left with the head elevated 10 degrees

26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation

The correct answer is A: Stay with client and observe for airway obstruction

65. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion

The correct answer is A: Stop the infusion

7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B)This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D)The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

The correct answer is A: Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.

99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens

The correct answer is A: Wash hands thoroughly before and after client contact

51. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip

The correct answer is A: administer the medication in 2 separate injections

48. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap."

The correct answer is B: "I am allergic to shrimp."

28. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."

The correct answer is B: "I have been coughing up foul tasting, brown, thick sputum."

59. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication."

The correct answer is B: "Our child should brush and floss carefully after every meal."

31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."

The correct answer is B: "The tube will remove excess air from your chest."

22. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake

The correct answer is B: Administer acetaminophen as ordered as this is normal at this time

96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

The correct answer is B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

23. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication

The correct answer is B: Assess for dyspnea or stridor

39. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

The correct answer is B: Assess for post operative arrhythmias

36. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

The correct answer is B: Assist client to turn, deep breathe, and cough

72. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

The correct answer is B: Check the client's gag reflex

81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

The correct answer is B: Continuously

87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

The correct answer is B: Decreased sodium and potassium

37. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises

The correct answer is B: Deep breathing and coughing

6. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness

The correct answer is B: Fever of 103 degrees F (39.5 degrees C)

4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output

The correct answer is B: Have the client turn to the left side

67. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets

The correct answer is B: Hemoglobin and hematocrit

84. Which statement best describes the effects of immobility in children? A) Immobility prevents the progression of language and fine motor development B) Immobility in children has similar physical effects to those found in adults C) Children are more susceptible to the effects of immobility than are adults D) Children are likely to have prolonged immobility with subsequent complications

The correct answer is B: Immobility in children has similar physical effects to those found in adults

3. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A)It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B)It is critical to report promptly to your health care provider any findings of peptic ulcers c)Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D)With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

The correct answer is B: It is critical to report promptly to your health care provider any findings of peptic ulcers.

13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles

The correct answer is B: Jugular vein distention

75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight

The correct answer is B: Obtain a health and dietary history

88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements

The correct answer is B: Oozing liquid stool

17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

The correct answer is B: Pale mucosa of the eyelids and lips

47. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator

The correct answer is B: Perform a quick assessment of the client''s condition

64. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin

The correct answer is B: Potassium

15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses

The correct answer is B: Pupils fixed and dilated

79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A)Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream

The correct answer is B: Sliced turkey sandwich and canned pineapple

55. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion

The correct answer is B: Sore throat, fever

66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended

The correct answer is B: Sudden cessation of alprazolam

30. Which of these observations made by the nurse during an excretory urogram indicate a complication? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."

The correct answer is B: The client's entire body turns a bright red color

100. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw

The correct answer is B: roast beef, mashed potatoes, and green beans

11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter

The correct answer is C: minimal drainage into the urinary collection bag

98. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.

The correct answer is C: "Children are not to share hats, scarves and combs."

54. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."

The correct answer is C: "The medication must be continued so the fluid problem is controlled."

5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea

The correct answer is C: A cold, pale lower leg

89. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain

The correct answer is C: Accept the client''s report of pain

57. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time

The correct answer is C: Activated PTT

46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

The correct answer is C: Assist him to stand by the side of the bed to void

33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms

The correct answer is C: Dyspnea

9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A)It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B)In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C)Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D)Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks

The correct answer is C: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent

82. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerine suppositories B) Fiber supplements C) Laxatives D) Stool softeners

The correct answer is C: Laxatives

45. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output

The correct answer is C: Loss of pulse in the extremity

40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs

The correct answer is C: Lower the oxygen rate

12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive

The correct answer is C: Participate with the compressions or breathing

77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs

The correct answer is C: Perform frequent oral care with a tooth sponge

92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

The correct answer is C: Place in respiratory/secretion precautions

34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak

The correct answer is C: Pulse oximetry of 88

42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

The correct answer is C: Reinforce the dressing and elevate the leg

73. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence

The correct answer is C: Reposition every two hours

8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A)Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. * C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

The correct answer is C: The flow of life is believed to flow through major pathways or nerve clusters in your body.

53. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure

The correct answer is C: improved respiratory status and increased urinary output

91. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors

The correct answer is C:Visitors should wash their hands before and after touching the client

69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."

The correct answer is D: "I always make sure to shake the NPH bottle hard to mix it well."

16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A)"I knew this would happen. I've been eating too much red meat lately." B)"I really enjoyed my fishing trip yesterday. I caught 2 fish." C)"I have really been working hard practicing with the debate team at school." D)"I went to the health care provider last week for a cold and I have gotten worse."

The correct answer is D: "I went to the doctor last week for a cold and I have gotten worse."

86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

The correct answer is D: Altered patterns of urinary elimination related to nocturia

62. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

The correct answer is D: Application of pediculicides

38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene

The correct answer is D: Assist with oral hygiene

71. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato

The correct answer is D: Baked potato.

80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall

The correct answer is D: Bed in lowest position, wheels locked, place bed against wall

97. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contac

The correct answer is D: Contact

44. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

The correct answer is D: Continue to monitor the rate of drainage

25. A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.

The correct answer is D: Fibroids that cause no problems still need to be taken out.

58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube Skip

The correct answer is D: Flush adequately with water before and after using the tube

21. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

The correct answer is D: Hair loss

1. Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

The correct answer is D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days Skip

The correct answer is D: No bowel movement for 3 days

60. Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding

The correct answer is D: Occult bleeding

20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

The correct answer is D: Pale, thin arms and legs, uninterested in surroundings

32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L

The correct answer is D: Serum potassium 6 mEq/L

52. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation

The correct answer is D: prevent the drug from tissue irritation

35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

The correct answer is D: restlessness

2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight

The correct answer is D: weekly weight

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:

The degree of fetal lung maturity

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:

The degree of fetal lung maturity Rationale: Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex and age of the fetus are not determined with the use of amniocentesis.

A client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid daily in a divided dose. At the health care provider's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that:

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that:

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

Which principle should the nurse use to delegate client care

The scope of practice defines which nursing interventions that can be delegated

What clinical problem is a suitable for research utilization in nursing?

The value of calcium channel blockers use over ACE inhibitors

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note?

Thick and opaque

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the health care provider with the procedure, expect to note?

Thick and opaque Rationale: Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect descriptions of the fluid that occurs in this disorder.

A child with growth hormone deficiency will be receiving somatropin. The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring?

Thyroid-stimulating hormone (TSH)

A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to:

Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10

A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to:

Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Rationale: Kegel exercises strengthen the muscles of the pelvic floor. To perform the exercises, the client is taught to tighten the pelvic muscles to a slow count of 10, then relax to a slow count of 10. The client is also instructed to do this exercise 15 times while lying down, sitting up, and standing (a total of 45 repetitions). The client is told that an improvement in the control of urine will be noticed after several weeks of the exercises; some individuals report that improvement takes as long as 3 months.

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers

Tissue ischemia

Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client:

To contact the health care provider

Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client:

To contact the physician

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?

Tongue protrusion Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia.

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which finding does the nurse expect to note?

Top layer of skin off Rationale: A stage I ulcer is characterized by intact skin that is red and does not blanch under external pressure. A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage III ulcer is characterized by full-thickness skin loss, and the subcutaneous tissue may be damaged or necrotic. The damage extends down to but not through the underlying tissues. A deep crater-like appearance or eschar is present. A stage IV ulcer is characterized by full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Sinus tracts may develop.

A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important?

Trapeze bar

An 80 year old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urniary retention in this geriatric client. ?

Tricyclic antidepressants Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D).

Which client information should the nurse obtain that is indicative of the presence of cholelithiasis?

Upper right abdominal pain that occurs after meals and radiates to the back or right shoulder.

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which finding would be of greatest concern to the nurse?

Urinary specific gravity is low

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which of these findings would be of greatest concern to the nurse?

Urinary specific gravity is low

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:

Urine output must be measured and that the health care provider should be notified if output is less than 500 mL in a 24-hour period Rationale: Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg, proteinuria is no more than 500 mg/day (trace to 1+), and symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet should provide ample protein and calories, and fluid and sodium should not be limited. The disease is considered severe when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours). Therefore, urine output of less than 500 mL/24 hr should prompt the client to notify the health care provider.

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:

Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period

The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care?

Use a bedside cool-mist vaporizer during naps and night time.

The nurse is instructing a mother about the care of her child who has pediculosis capitis....

Use a fine-toothed comb or tweezers to remove nits.

Which info should the nurse provide a client who has undergone cryrosyrgery for stage 1A cerviacl cancer?

Use a sanitary napkin instead of a tampon. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported.

The nurse plans to suction a male client. Who has just undergone right pneumonectomy for cancer of th lung. Secretions can be seen around the endotracheal tube and the nurse osculates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?

Use a soft tip rubber suction catheter and avoid deep vigorous suctioning. A soft rubber catheter with a blunt tip is preferable (B) and deep, vigorous suctioning (D) should be avoided. The client should not hold his breath (A) whether he has one or two lungs and 5 seconds of suctioning is not enough to justify the trauma caused by suctioning. Having another person available for restraint is a good idea if the client is combative or confused, but (C) is not the best answer to this question. It is important to avoid (D) in order to avoid perforating the sutures on the bronchial stump following a pneumonectomy.

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply.

Use a straw to drink. Use caution when leaning forward or backward. Do not drive, because full range of vision is impaired with the device.

What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration?

Use of a compression dressing for firm pressure to the site

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an IOP of 28 mmHg. What information should the nurse ask the client?

Use of prescribed eye drops since last exam by ophthalmologist.

A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?

Uteroplacental insufficiency during a contraction

A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interprterm-33et this finding?

Uteroplacental insufficiency during a contraction Rationale: The observation that the has nurse noted in this tracing is late decelerations. Late decelerations constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly associated with a contraction. Early decelerations result from pressure on the fetal head during a contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability refers to the difference between successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly.

Prior to a cardiac cauterization, which activity should the nurse have the client practice?

Valsalva's maneuver and coughing Before the cardiac catheterization, the client should practice techniques (e.g., Valsalva's maneuver, coughing, deep breathing) that will be used during the procedure (B). The client should keep the leg straight, not (A), for the prescribed number of hours post cardiac catheterization to prevent bleeding from the arterial access site. (C) is not used in this procedure. The client may be asked to change position during the procedure, so (D) is not necessary.

A nurse provides dietary instructions about foods that will promote healing to a client diagnosed with osteoporosis who has sustained a fracture. The nurse tells the client that it is best to consume foods that are high in:

Vitamin C

A male client has a prescription for disulfiram

Vomiting

A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next?

When did the symptoms begin after the last dose of opiate analgesic? Moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea, muscle cramps, and elevated blood pressures greater than 110 systolic or 70 diastolic. The onset of withdrawal for opiate analgesics typically coincides with the time of the next habitual drug dose at 4-6 hours and may last as long as 7 to 14 days, so determining the time of the last dose (D) pinpoints the relationship of opiate dependency and withdrawal symptoms. (A and B) are treatment options prescribed for withdrawal once further information is collected. (C) may be helpful information, but (D) is more focused and helps to differentiate the symptoms from a viral syndrome.

A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication:

With food

A client with acute gouty arthritis is being started on medication therapy with indomethacin.The nurse, providing medication instructions, and tells the client to take the medication:

With food

A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin (Glucophage) 850 mg/day has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered:

With the morning meal

A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin daily has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered:

With the morning meal

The nurse obtains the pluse rate of 89 beats/min for an infant before administering digoxin (Lanoxin) which action should the nurse take?

Withhold the medication and contact the healthcare provider Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity.

A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record?

Writing down the client's words and placing them in quotation marks

A client diagnosed with tuberculosis will be taking pyrazinamide, and the nurse provides instructions about the adverse effects of the medication. For which occurrence does the nurse tell the client to contact the health care provider?

Yellow skin

A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings?

Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive Proper documentation of abuse as reported by the victim is crucial, and (D) is specific and gives an accurate depiction of the events without documentation of judgmental inferences. (A, B, and C) lack specificity and important details related to the event.

The client is receiving an IV infusion of heparin. The bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. The heparin is to be infused at 1200 units per hour. At what rate should the nurse set the infusion pump? Calculate and record the rate in milliliters. Calculate and record the answer in the box.

Your Response: Correct Response: 24 mL X = 24

A client receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many units of heparin is the client receiving during an 8-hour shift? Calculate and record the answer in the box.

Your Response: Correct Response: 8800 units 50 units heparin/1 mL 50 units x 22 = 1100 units per hour 1100 units x 8 = 8800 units heparin