Practice test 3

Which of the following instructions should a nurse provide to a patient who has history of venous leg ulcers in order to prevent recurrence? "Sit with your legs dependent whenever possible." "Use warm compresses on your legs in the evening." "Examine your legs for areas of redness every day." "Keep your legs flexed when standing for long periods."

"Examine your legs for areas of redness every day." Explanation: Client Need: Physiological Integrity Rationale: C. Instruct the patient and family to observe the skin daily for changes and to maintain good foot are. A. The Patient legs should be elevated to promote venous return. B. The patient should avoid direct heat application to the extremities. D. The patient should avoid standing or sitting in one position for lengthy periods of time.

A patient who has hyperthyroidism is taking methimazole (Tapazole and attends the clinic regularly. To evaluate the effectiveness of Tapazole therapy, the nurse should consider which of the following questions? "Has the patient's vision improved?: "Has the patient's appetite improved?" "Has the patient's need for sleep decreased?" "Has the patient's pulse rate decreased?"

"Has the patient's pulse rate decreased?" Explanation: Client Need: Physiological Integrity Rationale: D. Tapazole is used to decrease iodine use and inhibit the synthesis of thyroid hormones. Therefore, metabolic activity will be decreased if the treatment is effective. A. Tapazole does not improve vision. B. The patient's appetite should decrease secondary to decreased metabolic rate. C. The patient should have more restful sleep when the metabolic rate is decreased

Which of the following statements made by a patient who is being discharged with a posterior nasal pack, indicates that the patient needs FURTHER instruction? "I will irrigate the packing daily." "I will change the packing every two days." " will cough and deep breathe four times a day." "I will take antibiotics until the packing is removed."

"I will take antibiotics until the packing is removed." Explanation: Client Need: Physiological Integrity Rationale: D. Antibiotics are used to prevent toxic shock syndrome and sinusitis in patients with nasal packing. A and B. These options are not documented as interventions following insertion of posterior nasal packing. The packing, when inserted, is positioned above the pharynx. If it slips from position, it can cause airway obstruction. C. With posterior nasal packing in place, the patient will be mouth breathing. Gag and cough reflexes should be maintained. Precautions should be taken so that the packing does not slip and cause airway obstruction.

A patient has had a basal cell carcinoma removed. Which of the following patient statement would indicate to the nurse a need for FURTHER instruction? " will use sunscreen with at least a sun protection factor (SPF) of 15." "I will use tanning booths rather than sunbathing from now on." "I will stay out of the sun between 10:00 a. m. and 2:00 p.m." "I will wear a broad-brimmed hat when I am in the sun."

"I will use tanning booths rather than sunbathing from now on." Explanation: Client Need: Health Promotion and Maintenance Rationale: B. The use sun lamps or commercial tanning booths should be avoided. A, C and D. These measures indicate a correct understanding of the precautions to be taken by patients with basal cell carcinoma.

Because a woman is planning to breast-feed her infant, measures to prevent her nipples from becoming sore were discussed. Which of the following comments made by the woman would indicate that she understood the instructions? "I'll use a nipple shield with every other breastfeed during my first postpartum week." "I'Il cleanse my nipples with soap and water before each feeding." "I'll expose my nipples to the air several times a day." "I'll apply an antiseptic cream to my nipples after each feeding."

"I'll expose my nipples to the air several times a day." Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Exposure of nipple to air help to toughen the tissue and decrease the risk of sore nipples. A. Nipple shield are not used routinely by breastfeeding mothers. B. Soap should be avoided. Water only is needed to keep the nipple clean D. No antiseptic creams should be used on the nipples.

A patient is brought to the emergency department following a severe automobile accident. By the time the patient's spouse arrives, the patient has died. The spouse demands to see the body. Which of the following responses should a nurse make? "It would be best for you to talk to the doctor first." "You really don't want to see your spouse. The injuries are too severe." "If you wish, I will stay with you while you are with your spouse." "You might want to talk to your children before you see your spouse."

"If you wish, I will stay with you while you are with your spouse." Explanation: Client Need: Psychosocial Integrity Rationale: C. Offering to stay with the spouse is a way of providing support through a difficult event that can be traumatic. A. The spouse does not need to speak with the physician before he sees his wife's body. B. This response takes away the spouse's choice and implies that the spouse may not be strong enough for the task. D. This response postpones the action and does not address the spouse's needs.

Which of the following suggestions should a nurse make to a known poly-substance-abusing woman who is 18 weeks pregnant? "If you cannot stop taking drugs, you might consider terminating the pregnancy." "You should stop using all drugs immediately before your baby develops birth defects." "If you enter the drug treatment program now, you baby will be born healthy." "It may not be possible for you to stop drugs completely, but you should consider limiting the drugs you use during pregnancy."

"It may not be possible for you to stop drugs completely, but you should consider limiting the drugs you use during pregnancy." Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Women who are drug dependent need nursing support and anticipatory guidance during pregnancy since they have few support systems with whom they can discuss their concerns and fears. The nurse would encourage the woman to decrease her drug activity during pregnancy. A. This statement is judgmental and harsh, and would not encourage the woman to discuss her concerns with the nurse. B. This statement withdrawal from heroin may be associated with decreased blood flow to the placenta and thus is not advocated by all health care professionals. C. The nurse is offering false hope to the woman since the nurse cannot say with certainly that damage to the fetus has not already occurred.

A young boy who is receiving chemotherapy develops alopecia and says to the nurse, "I've lost all my hair." Which of the following responses would be APPROPRIATE for the nurse to make to the child? "Did you know that because your hair fell out, we know that the medicine is working to make you better?" "Would you like to see some pictures of famous men who are bald?" "It's hard to look different from the way you used to look." "You can wear a baseball cap until your hair grows back."

"It's hard to look different from the way you used to look." Explanation: Client Need: Psychosocial Integrity Rationale: C. This response encourages the teenager to elaborate about his body image. A. Hair loss in a side effect of chemotherapy and not an indicator of the effectiveness of treatment. B. This response may help the teenager to identify with someone else who does not have hair, but it should not be the nurse's initial response. D. The nurse can other suggestions for how to handle the hair loss, but the nurse's initial response should be directed toward getting the patient to talk about his feelings.

A patient diagnosed with post-traumatic stress disorder (PTSD) was troubled by frequent nightmares. The patient asks the nurse, "What's wrong with me?" Which of the following responses by the nurse would be MOST therapeutic? "Many people experience intense reactions following a frightening experience." "Nightmares are means of working off psychic energy." "Nothing is wrong with you." "Why do you think there's something wrong with you?"

"Many people experience intense reactions following a frightening experience." Explanation: Client Need: Psychological Integrity Rationale: A. Diagnostic criteria for posttraumatic stress disorder include exposure to a traumatic event in which the person was confronted with actual or threatened death, and the person experienced fear, helplessness and or horror. B. This response does not reply to the patient's question and does not let the patient know why the nightmares are occurring. C. This response negates the patient's feelings and concerns D. This response minimizes the patient's awareness that there is a problem.

Which of the following comments made by the spouse of a patient who has been newly diagnosed with schizophrenia, would indicate that the spouse has understanding of the disorder? "I can't wait for these illness-related problems to disappear." "My spouse and I will need ongoing psychiatric support in the community." "T'Il be glad when my spouse becomes the person I married again." "My spouse will no longer live with me because permanent hospitalization is necessary."

"My spouse and I will need ongoing psychiatric support in the community." Explanation: Client Need: Psychosocial Integrity Rationale: B. Information on community resources should be made available to patients and families alike. Family education and family therapy are known to diminish the negative effects of family life on schizophrenics. A and C. Patients and families should be made aware that schizophrenia is a relapsing disorder. D. When s schizophrenic patient return to a family environment consisting of warmth, concern and support, a relapse is less likely to occur.

Which of the following instructions regarding skin care should a nurse give to a patient who is receiving radiation therapy? "Cover the irradiated area with a light gauze dressing." "Rinse the irradiated area with normal saline solution. "Apply petroleum-based ointment to the treatment area." "Use a mild soap to cleanse the affected area."

"Use a mild soap to cleanse the affected area." Explanation: Client Need: Physiological Integrity Rationale: D. The irradiated area should be cleansed daily with water, or with a mild soap and water. A. The irradiated areas does not need to be covered with a dressing. B. The involved area needs only to be cleansed with water and not with saline solution. C. Powders, ointments, lotions and creams are not be used on the irradiated site unless ordered by the physician.

An infant born at 34 weeks gestation is at risk for respiratory synctial virus (RSV). When teaching the family about health promotion, what is primary recommendation should the nurse give to the parents? "Avoid group settings of other children if at all possible." "Limit visitation of the infant by anyone who has a cold." "Use good hand washing techniques." "Keep the baby out of drafts."

"Use good hand washing techniques." Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Respiratory synctial virus is the causative organism n bronchiolitis. Good hand washing techniques are essential to prevent eh spread of the virus. A, B and D. Rest, oxygen and hydration are the essential aspects of care for the infant with respiratory synctial virus. A cool must humidifier is recommended if the room air is dry. Visitors do not have to be limited, but the family should be aware that the infant probably will be fatigued, irritable, anxious and unable to eat or sleep.

A patient who has terminal cancer has an order for morphine sulfate (MS Contin) tablets every 8 to 12 hrs p.r.n. for moderate pain or morphine sulfate injections of 10 to 12 mg every four hours p.r.n. intramuscularly for severe pain. The patient has been receiving MS Contin p.o. every 12 hours but is experiencing breakthrough pain after about 10 hours. Which of the following nursing action is MOST APPROPRIATE? Administer injectable morphine sulfate, 12 mg, IM, p.r.n. Administer the MS Contain, po, every 12 hours. Administer the MS Contain, po, every 10 hours. Withhold the pain medications and notify the physician.

Administer the MS Contain, po, every 10 hours. Explanation: Client Need: Safe Effective Care Environment Rationale: C. The pain medication should be administered before the pain begins to increase rather than when it becomes severe. When administered in this manner, the patient usually requires far less pain medication. The patient's order permits the morphine after eight hour. The nurse should begin a schedule of every 10 hours rather than every 12 hours. A. The p.r.n. injection is for severe pain. There is breakthrough pain occurring but there is no indication that it is severe. B. The patients is having breakthrough pain after 1- hours. The oral medication needs to be administered more frequently than every 12 hours. D. There is no need to notify the physician since the orders already written cover this situation. The nurse should chart the change in medication administration as well as the outcome of the new medication schedule. Withholding the analgesic will make the pain more severe and should not be done.

Which of the following nursing diagnoses should the nurse PRIORITIZE when planning care for a patient who has cardiogenic shock? Risk for infection Altered nutrition: less than body requirements Altered tissue perfusion: peripheral Fluid volume deficit

Altered tissue perfusion: peripheral Explanation: Client Need: Physiological Integrity Rationale: C. Cardiogenic shock occurs when the contractility of the cardiac muscle is directlv impaired. Vasodilatation results in a declining blood pressure and altered tissue perfusion. The priority nursing diagnosis is altered tissue perfusion: peripheral. A, B and D. The Priority for nursing care of the patient in cardiogenic shock is maintaining organ perfusion and not preventing infection, administering nutrients or administering

A community health nurse teaches a mother comfort measures for her six-year-old child who has varicella zoster. Which of the following actions by the mother requires FURTHER intervention? Applying a cortisone-based cream to the child's lesions. Patting the child's lesions with calamine lotion. Bathing the child in a tepid oatmeal bath. Trimming the child's fingernails very short.

Applying a cortisone-based cream to the child's lesions Explanation: Client Need: Safe Effective Care Environment Rationale: A. Medications that affect wound healing, such as corticosteroids, impair phagocytosis, inhibit fibroblast proliferation, depress formation of granulation tissue and inhibit wound closure. They should not be used by patients with varicella. B. Calamine lotion provide supportive therapy for patients with varicella. C. Oatmeal baths are helpful and soothing. D. Children are prone to scratching the lesions. Keeping the fingernails short may prevent scarring.

Which of the following measures is MOST important when providing nursing care for a patient who has disseminated intravascular coagulation (DIC)? Avoiding intramuscular injections. Limiting green, leafy vegetables. Using automatic blood pressure cuffs. Providing meticulous oral care.

Avoiding intramuscular injections Explanation: Client Need: Physiological Integrity Rationale: A. Patients with disseminated intravascular clotting (DIC) develop a bleeding disorder, and may bleed from mucous membranes, venipuncture sites and the gastrointestinal and urinary tracts. Intramuscular injection should be avoided. B, C and D. Dietary restrictions, used of automatic blood pressure cuffs and meticulous oral care are not the most important nursing measures for the patient with DIC.

Which of the following findings would a nurse expect to assess in a patient who has lower lobe pneumonia? Paradoxical chest movement Eupnea Bronchial breath sounds Kussmaul respirations

Bronchial breath sounds Explanation: Client Need: Physiological Integrity Rationale: C. Bronchial and bronchovesicular sounds that are audible in the lungs signify pathology. Usually they indicate consolidated areas in the lungs (e.g. pneumonia, heart failure) and necessitate further evaluation. A. Paradoxical chest movement is not identified as a symptoms of pneumonia. It indicates flail chest. B. Eupnea is normal, quiet breathing D. Kussmaul breathing is deep, rapid breathing, a dyspnea occurring in paroxysms and often preceding diabetic coma.

When assessing a woman who is in 6th day postpartum, a nurse would expect to describe the lochia in which of the following ways? Red in color with occasional small clots Brown in color without clots Pink in color with occasional small clots White in color without clots

Brown in color without clots Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Lochia serosa (pink or brown) begins three to four days after childbirth and continues to about 10 days, when it changes to lochia alba, a yellow to white discharge. A. Clots are described only with lochia rubra (dark red) which occurs up to three to four days after delivery. C. Clots are not described with lochia serosa (pink) D. Lochia alba occurs 10 days after delivery

The mother had difficult labor and an unexpected cesarean delivery has been ordered STAT. They voice their displeasure with the way the situation was handled and are threatening to sue. As the nurse caring for this family, you will: carefully document your care on the patient's chart. delegate routine care to other personnel. go into the room only when called, to allow for privacy. contact the hospital legal advisor prior to giving care.

Carefully document your care on the patient's chart Explanation: Client Need: Safe Effective Care Environment Rationale: A. All care should be carefully documented on the chart, which becomes a legal document. The chart may be subpoenaed in court and only that care which is documented is considered to have actually been done. B. Delegating routine care to other personnel is not an appropriate response by the nurse. The nurse should continue to care for the family unless requested not to do so. C. Going into the room only when called indicates avoidance of the situation and may be misconstrued by the family. D. The hospital legal advisor should be made aware of the situation but does not need to be contracted prior to care.

A four-month-old infant who has acquired immune deficiency syndrome (AIDS) and is living with the biological mother would receive the injectable form of polio vaccine for which of the following reasons? Improved absorption Improved immunity Decreased viral shedding Decreased risk of anaphylaxis

Decreased viral shedding Explanation: Client Need: Safe Effective Care Environment Rationale: C. Increased protection against wild polio virus by oral poliovirus vaccine (OP) occurs because this vaccine immunizes the gastrointestinal tract. Shedding of OVP is a danger to contacts who are immunocompromised, such as patients with AIDS. For this reason the injectable form of the polio vaccine is given. A. The vaccine is given by injection to avoid viral shedding and not because of absorption. B. Oral polio vaccine is more effective in preventing the spread of wild polio viruses than the injectible form. D. Oral poliovirus vaccines has caused vaccine- related paralysis in both recipients and contacts. Because of the greater risk of vaccine- related paralysis in children with immunodeficiency disease, injectible polio vaccine is the treatment of choice for immunocompromised children and any close contacts because it does not have a history of causing vaccine related paralysis.

Which of the following questions is MOST important for a nurse to ask when taking a history from a patient who presents with symptoms of peripheral arterial occlusive disease? "Do your legs hurt while walking?" "Do you notice swelling in your legs at night?" "Do you have calf pain when you flex your foot?" "Do vou feet feel warm after exercise?"

Do your legs hurt while walking? Explanation: Client Need: Physiological Integrity Rationale: A. Pain while walking is a sign of intermittent claudication and arterial insufficiency. B. There is minimal swelling associated with peripheral arterial occlusive. Swelling occurs with venous insufficiency. C. Complaints of pain in the calf on dorsiflexion of the foot is a positive Homan's sign, and is diagnostic of thrombophlebitis. D. The client with peripheral arterial insufficiency has skin with a cool to cold temperature.

Before administering the measles, mumps and rubella (MMR) vaccine to a 12-year-old child, it is essential that a nurse assess for an allergy to: peanuts. eggs. seafood. milk.

Eggs Explanation: Client Need: Safe Effective Care Environment Rationale: B. Measles vaccine is contraindicated in patients who have had an allergic reaction to eggs. The child may be able to receive the measles, mumps and rubella (MMR) vaccine after a desensitization program. A, C and D. Allergies to peanuts, seafood or milk do not affect administrations of the MMR vaccine.

Which of the following conditions would the nurse recognize as contributing factor to the development of respiratory acidosis? Emphysema Hyperventilation Diarrhea Achalasia

Emphysema Explanation: Client Need: Physiological Integrity Rationale: A. Chronic respiratory acidosis occurs with pulmonary disease such as chronic emphysema and bronchitis, obstructive sleep apnea and obesity. B. Respiratory alkalosis is always due to hyperventilation. C. Normal anion gap acidosis (metabolic acidosis) results from direct loss of bicarbonate, as in diarrhea. D. Achalasia is not identified as contributing to any acid- based disorder. Achalasia is a disorder in which the lower esophageal muscles and sphincter fail to relax appropriately in response to swallowing.

A patient is admitted to the unit with a tentative diagnosis of Hodgkin's disease. Which of the following findings are MOST significant in supporting this diagnosis? Change in mental status Dependent edema Distended abdomen Enlarged lymph nodes

Enlarged lymph nodes Explanation: Client Need: Physiological Integrity Rationale: D. Hodgkin's disease usually originates in single lymph node, or a single chain of lymph nodes. A, B and C.While these manifestations may occur, they are not specific to Hodgkin's disease. Dependent edema and a distended abdomen re found in conditions associated with fluid volume excess.

Which of the following conditions should the nurse recognize as contributing factor to the development of respiratory alkalosis? Chronic obstructive pulmonary disease (COPD) Episodes of hyperventilation Frequent loose stools Hiatal hernia

Episodes of hyperventilation Explanation: Client Need: Physiological Integrity Rationale: B. Respiratory alkalosis is due to hyperventilation, which causes excessive "blowing off" of carbon dioxide and, hence, a decrease in plasma carbonic acid concentration. A. Chronic obstructive pulmonary disease is associated with respiratory acidosis since the patient retains carbon dioxide. C. Frequent loose stools (diarrhea) can cause normal anion gap acidosis metabolic acidosis). D. Hiatal hernia is not associated with a blood gas abnormality. However, excessive ingestion of antacids containing bicarbonate can cause metabolic alkalosis.

Which of the following actions would a nurse take FIRST when caring for a patient who is experiencing cardiac arrest? Initiate cardiac monitoring. Provide intravenous access. Establish a patent airway. Obtain a pulse oximetry reading.

Establish a patent airway. Explanation: Client Need: Safe Effective Care Environment Rationale: C. The initial priority during a cardiac arrest is the maintenance of a patient airway. A, B and D. Initialing cardiac monitoring, providing intravenous access and obtaining a pulse oximetry reading may be done during the process of a cardiac arrest but an open airway is the first priority.

A two-year-old is being discharged from the ambulatory surgery center 10 hours after undergoing a tonsillectomy. Which of the following findings would prompt the nurse to delay the discharge? Complaints of pain Frequent swallowing Refusing to speak Continual mouth breathing

Frequent swallowing Explanation: Client Need: Physiological Integrity Rationale: B. The nurse should watch for tachycardia, pallor and excessive swallowing. Swallowing indicates that blood is trickling down the child's throat. The throat is checked with a flashlight to assess for bleeding. A. Children describe the throat as being "Very sore" after a tonsillectomy. Such an indication would not delay discharge. C. Since the throat is sore, many children refuse to speak. This would not delay discharge. D. Mouth-breathing is expected following a tonsillectomy. Preoperatively, inflamed tonsils may partially obstruct the passage of food and air. If adenoids are also swollen, it may be difficult for air to pass from the nose to the throat. Postoperatively, some swelling may persist; therefore, mouth- breathing may continue. A cool vaporizer keeps mucous membranes moist during mouth- breathing.

A patient in the recovery room complains of incisional pain. Which of the following nursing interventions would be MOST APPROPRIATE? Give meperidine (Demero) 50 mg, IM, as ordered. Encourage deep breathing exercises. Place the patient in a prone position. Give acetaminophen (Tylenol), two tablets as ordered.

Give meperidine (Demero) 50 mg, IM, as ordered. Explanation: Client Need: Safe Effective Care Environment Rationale: A. Intramuscular pain medication should be administered as ordered in the immediate postoperative period so that the pain does not become severe and interfere with recovery. B. Deep breathing encourages lung expansion but does not relieve incisional pain. C. The prone position would not be comfortable for the patient if there is an abdominal or chest incision. D. Tylenol usually is not strong enough to relieve incisional pain in the immediate postoperative period. Medication is administered intramuscularly or intravenously until the patients is fully reactive and no longer NPO.

A child presents with periorbital edema, dark-colored urine and decreased urine output. A PRIORITY question for the nurse to ask when obtaining the history from the parent is.: "Has your child been diagnosed recently with strep throat?" "Does you child experience shortness of breath when playing?" "Is there any history of liver disease in the family?" "Does your child seem to be more tired than usual?"

Has your child been diagnosed recently with strep throat Explanation: Client Need: Physiological Integrity Rationale: A. Manifestations such as periorbital edema, dark- colored urine and decreased urinary output indicate glomerulonephritis, which occurs after a streptococcal infection. B and D. Shortness of breath and fatigue are not generally related to glomerulonephritis C. Glomerulonephritis is not related to a history of liver disease in the family

Which of the following laboratory result identified in a patient who is experiencing vomiting and diarrhea, is most suggestive of hypovolemic shock? Your Answer: & Incorrect Potassium, 5.6 mEq/L Hematocrit, 58% Hemoglobin, 11g/dL Calcium, 6 mEq/ L

Hematocrit, 58% Explanation: Client Need: Physiological Integrit Rationale: B. Hematocrit levels above 47% in females and 52% in males are indicative of dehydration that can result from hypovolemic shock. A. A potassium level above the normal of 3.5- 5 mEq/L is not duet to hypovolemic shock. C. When hypovolemic shock is due to dehydration, such as with vomiting and diarrhea, the hemoglobin value is elevated, not decreased. D. Hypercalcemia is not the result of hypovolemic shock due to vomiting and diarrhea.

A nurse would expect a typical preschool-age child to display which of the following behaviors? Responding to requests by frequently using the term "no" Making change for a quarter. Imitating behavior of significant adults during play. Readily accepting a substitute babysitter.

Imitating behavior of significant adults during play. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. The preschooler characteristically is initiative, especially in faithfully reproducing the behavior of significant adults. A. Toddler hood is the period of the "terrible twos". A time of exploration of the environment as the child learns how things work, what the word "no" means and the power of temper tantrums. B. School-age children have the mental ability to make change out of a quarter by seven years of age. D. During the preschool period the individuation-separation process is complete. Preschoolers relate to unfamiliar people easily and tolerate brief separations from patents.

A nurse should inform a patient who is taking hydrochlorothiazide (Hydrodiuril) to make which of the following dietary changes? Limit green, leafy vegetables. Drink plenty of tomato juice. Decrease ingestion of red meat. Increase intake of oranges.

Increase intake of oranges. Explanation: Client Need: Physiological Integrity Rationale: D. Hydrochlorothiazide can cause hypokalemia. Oranges are a good source of potassium replacement and should not be restricted in the diet. A. Green, leafy vegetables are a source of postpartum and should not be limited. B. Tomato juice is not recommended because it has a high sodium content. C. There is no recommendation related to ingestion of red meat while taking hydrochlorothiazide.

A 24-hour postpartum woman has an episiotomy repaired. The nurse would be instructed to report which of the following findings immediatelv? Decreased urine output Absence of a daily bowel movement Presence of lochia rubra Increased perineal pain

Increased perineal pain Explanation: Client Need: Physiological Integrity Rationale: D. Signs of an infected episiotomy include pain, redness, warmth, swelling and discharge. A. Hormonal changes cause an increase in renal function during pregnancy. Decreased steroid levels may partially explain the reduction of renal function in the postpartum period. B. Spontaneous bowel evacuation may be delayed up to two to three days after childbirth. C. Lochia rubra begins to turn brown three to four days after childbirth.

A nurse observes a colleague taking all of the following actions when caring for a patient who has leakage of cerebrospinal fluid from the nose. Which action would require FURTHER discussion? Placing the patient in low-Fowler's position. Assisting the patient to void on a bedpan. Inserting gauze packing into the patient's nose. Shining a penlight into the patient's eyes.

Inserting gauze packing into the patient's nose. Explanation: Client Need: Safe Effective Care Environment Rationale: C. The nurse should not insert gauze packing into the nose of a patient. The nurse should further discuss this action with the colleague. A, B and D. Positioning a patient, assisting with voiding and checking papillary response to light are appropriate nursing interventions that do not warrant further discussion with the nurse's colleague.

A patient who has a diagnosis of metastatic cancer of the kidney was informed by the physician that the kidney needs to be removed. The patient asks the nurse. "What should I do?" Which of the following responses by the nurse would be MOST therapeutic? "Let's talk about your options." "You need to follow the doctor's advice." "What does your family want you to do." "I wouldn't have the surgery done without a second opinion."

Lets talk about your options Explanation: Client Need: Psychosocial Integrity Rationale: A. The nurse should provide an opportunity for the patient to ventilate and to discuss her concern. This response lets the patient know that there are care options and allows for discussion of treatment. B. This response minimizes the patient's participation in her won treatment plan. C. The most important issue in this situation is what the patient wants to do D. A second opinion might be encouraged but the best response by the nurse is to encourage the patient to talk about her concerns.

A nurse should include which of the following strategies in the care plan of a child who is receiving cyclophosphamide (Cytoxan) for treatment of Hodgkin's disease? Monitor the child's intake and output. Assess the child's apical heart rate. Place a footboard at the end of the child's bed. Evaluate the child's hemoglobin level.

Monitor the child's intake and output Explanation: Client Need: Physiological Integrity Rationale: A. Intake and output should be monitored. To prevent the development of hemorrhagic cystitis, fluid intake should be 1000- 2000 ml/ day. B. There is no indications for the necessity of monitoring apical pulse rate. C. Foot drop is a complication of treatment with vincristine (Oncovin). D. Administration of cyclophosphamide rarely causes anemia.

At 33 weeks of pregnancy, a woman who has been treated for pregnancy induced hypertension is readmitted to the hospital. She is placed on bedrest and started on magnesium sulfate therapy. Which of the following assessment is essential for the nurse to make? Obtaining weight daily. Measuring the abdominal circumference. Inspecting for jaundice. Papating for a symmetrical femoral pulses.

Obtaining weight daily Explanation: Client Need: Health Promotion and Maintenance Rationale: A. The mother's daily weight is of primary concern because it provides the nurse with a baseline and then a record of increasing weight. Sudden weight gain of four pounds or weight gain of one pound per week in the second and third trimesters are associated with preeclampsia. B. Abdominal circumference is not routinely measured. C. Jaundice is not an associated characteristic of pregnancy- induced hypertension or preeclampsia. D. Deep tendon reflexes and an assessment of pedal edema are more important than assessment of femoral pulses in the preeclamptic woman.

Which expected outcome should be given PRIORITY in the nursing care plan for a patient with adult respiratory distress syndrome (ARDS)? Systolic blood pressure greater than 90 mm Hg Oxygen saturation greater than 95% Respiration rate less than 20/ min Heart rate less than 100/ min

Oxygen saturation greater than 95% Explanation: Client Need: Physiological Integrity Rationale: B. The goal of nursing care for the patient with adult respiratory distress syndrome (ARDS) is to monitor the patient's response to the ventilator. This is achieved by monitoring non- invasive respiratory parameters, such as pulse oximetry, for oxygen saturation levels. A, C and D. Monitoring the identified vital signs is important, but does not take priority over monitoring the oxygen saturation level.

Which of the following concepts should a nurse emphasize when conducting a community education program on reducing the risk of rape? Rape rarely occurs in rural areas. The very young and the very old are usually safe from rape. People who walk in groups are less likely to be raped. Rape is a response to sexual need.

People who walk in groups are less likely to be raped. Explanation: Client Need: Psychosocial Integrity Rationale: C. Community education should indicate that when walking at night or in an isolated area, the best rape prevention strategy is not to walk alone. A. Rape occurs in both urban and rural areas. B. No age group is immune from rape. D. Rape is an act of anger, rather than a sexual act.

A nurse observes a nurse's aide taking all of the following measures when caring for a patient in the postoperative period following a pneumonectomy. Which action by the nurse aide would require immediate intervention by the nurse? Assisting the patient to ambulate in the hall Positioning the patient on the unoperated side. Placing elastic stockings on the patient's legs. Splinting the patient's chest during coughing.

Positioning the patient on the unoperated side. Explanation: Client Need: Safe Effective Care Environment Rationale: B. The post- pneumonectomy position is on the back or operated side only. The patient is not allowed to lie with the operated side uppermost because the bronchial stump might open, causing fluid to drain into the unoperated side. Lying on the back or operated side also allows for maximum expansion of the unaffected lung. The nurse should intervene if the aide is positioning the patient incorrectly. A, C and D. All of these are appropriate actions by the aide and do not require intervention by the nurse.

A patient is to receive an intramuscular injection of iron dextran (INFeD). Which of the following steps should a nurse take before administering the drug? Rotate the medication vial for one minute. Pull the skin to one side. Apply ice to the site. Change to a 25-gauge needle.

Pull the skin to one side. Explanation: Client Need: Safe Effective Care Environment Rationale: B. The Z-Track method of injection is used to administer iron dextran. The skin should be pulled sideways away from the muscle. A. The medication vial does not need to be rotated for one minute prior to injection. C. Ice should not be applied to the site prior to administration and may cause delay in absorption of the medication. D. The needle should be changed to a 22- gauge needle, two to three inches long.

When caring for a patient who is on a mechanical ventilator, the nurse should monitor the patient for which of the following complications? Flail chest Pleural effusion Pneumothorax Pulmonary embolus

Pulmonary embolus Explanation: Client Need: Physiological Integrity Rationale: C. Patients receiving mechanical ventilation can experience barotraumas, or damage to the lungs by positive pressure. Barotraumas includes pneumothorax, subcutaneous emphysema and pneumomediastinum. A. Mechanical ventilation is a treatment for flail chest rather than a complication B and D. Pleural effusion and pulmonary embolus are not complications of mechanical ventilation.

Which of the following nursing diagnoses would a nurse PRIORITIZE in the care of a patient whose blood test reveals a red blood cell count of 3.0 million/mm3? Risk for activity intolerance Risk for fluid volume deficit Risk for impaired skin integrity Risk for infection

Risk for activity intolerance Explanation: Client Need: Safe Effective Care Environment Rationale: A. Decreased RBC production can indicate anemia or hemorrhage. In either case the patient experiences fatigue due to decreased oxygen- carrying capacity. Priority should focus on risk for activity intolerance. B, C and D. Risk for fluid volume deficit, impaired skin integrity and infection are not priority nursing diagnoses of the patient with a decreased red cell count. Risk for activity intolerance should be the priority.

Which of the following nursing interventions would be most effective in helping a parent who is grieving the loss of a young child? Schedule times to discuss family pictures with the parent. Encourage the parent to have another child as soon as possible. Recommend frequent periods of sleep during the day. Distract the parent from thinking about the child.

Schedule times to discuss family pictures with the parent Explanation: Client Need: Psychosocial Integrity Rationale: A. Using memories is positive. This process goes on with great sadness, but is part of the resolution of grief. Using family pictures encourages the bereaved to think and talk about numerous memories. B. This response is not helpful and negates the importance of the deceased child and of the need for grieving. C. This response promotes avoidance in the patient. D. The patient needs to talk about the deceased child. This response may indicate to the patient that the nurse is uncomfortable talking about the child.

Anurse should assess a patient who has had a recent myocardial infarction for which of the following symptoms of pericarditis? Dull pain while sitting Burning pain in the chest Throbbing pain radiating to the jaw Sharp pain on inspiration

Sharp pain on inspiration Explanation: Client Need: Physiological Integrity Rationale: D. Pain associated with pericarditis is classically pleuritic and is aggravated by breathing, especially on inspiration. A. A dull pain while sitting may be indicative of angina. B. A burning pain in the chest may be indicative of esophageal reflux or angina. C. Throbbing pain radiating to the jaw may indicate a myocardial infarction.

Which of the following comments by a nurse would be MOST effective when dealing with a patient who has a diagnosis of severe (+3) anxiety? "Call me when you are calm enough to sit down" "Sit in this chair' "Where would vou like to sit?" "How would you feel about sitting down?"

Sit in this chair Explanation: Client Need: Psychosocial Integrity Rationale: B. The patient experiencing severe anxiety has a narrowed range of focus and responds best to simple instructions. A. This response does not provide either support or direction for the patient. C and D. The patient with severe anxiety has difficulty making decisions and responds best to simple direction.

Which of the following complications are MOST likely to develop in a patient who is undergoing mechanical ventilation? Stress ulcers Paralytic ileus Urinary retention Peripheral neuropathy

Stress ulcers Explanation: Client Need: Physiological Integrity Rationale: A. Stress ulcers occur in approximately 25 percent of patients receiving mechanical ventilation due to the stress of the ventilator and lack of food in the stomach. B, C and D. Paralytic ileus, urinary and peripheral neuropathy are not complications of mechanical ventilation.

A patient who had a tonsillectomy reports spitting up copious amounts of blood at home 10 days after the surgery. Which of the following actions would the nurse instruct the patient to take FIRST? Take nothing by mouth and go to the emergency room. Gargle with warm saline solution. Drink ice cold water. Apply direct pressure to the carotid artery.

Take nothing by mouth and go to the emergency room. Explanation: Client Need: Physiological Integrity Rationale: A. Hemorrhage may occur up to 10 days after surgery as a result of tissue sloughing from the healing process. Any sign of bleeding warrants immediate medical attention. B, C and D. None of these measures will stop post tonsillectomy hemorrhage. The first priority is medical attention.

Which of the following behaviors would indicate the greatest improvement in a patient who was admitted to the hospital with a diagnosis of hyperactivity? The patient completes an assigned task. The patient frequently apologizes for his behavior. The patient takes naps during the day patient on the unit. The patient on the unit intrudes other patients' activities.

The patient completes an assigned task. Explanation: Client Need: Psychosocial Integrity Rationale: A. Completing an assigned task indicates that the patient's anxiety is under greater control, that his concentration has improved, and that he can tolerate focusing on an activity. B. Frequently apologizing for behavior indicates that the patient is still not able to control his impulses. C. Often the hyperactive patient, experiences exhaustion and falls asleep. Napping does not indicate that the hyperactivity is under control. D. Often this type of interest is intrusive and indicates an inability to set limits on one's own behavior.

Which of the following responses of a female patient who is codependent and has low self-esteem indicates that nursing interventions have been successful? The patient encourages her 16-year-old daughter to prepare her own breakfast. The patient regularly prepares refreshments for her reading club. The patient refuses help from her child with meal preparation. The patient seeks other family member's approval prior to preparing meals.

The patient encourages her 16-year-old daughter to prepare her own breakfast. Explanation: Client Need: Psychosocial Integrity Rationale: A. Co-dependents try to control events and people around them. The fact that the woman is encouraging her daughter to make her own breakfast, rather than making it for her, shows that the interventions have been successful. B, C and D. All of these responses demonstrate codendency rather than improvement in the patient.

A patient expresses many physical complaints during the first two weeks on the alcohol rehabilitation unit. The results of physical examination have been negative. The patient frequently approaches staff members to request medication for her discomfort. Based on the patient's behavior, which of the following interpretations is CORRECT? The patient is trying to make the staff feel guilty. The patient is attempting to relive her anxiety. The patient is experiencing organic pain from alcohol withdrawal. The patients is using a more mature way of meeting her needs than alcohol.

The patient is attempting to relieve her anxiety Explanation: Client Need: Psychosocial Integrity Rationale: B. The patient detoxifying from alcohol and other drugs experiences anxiety because the patient's usual coping mechanism is removed, Consequently, the patient will often use any method to obtain a drug, including feigning illness. When the patient complains, he/ she should be assessed for the presence of a physical illness. In the absence of illness, the patient's behavior can be seen as an attempt to control anxiety. A. The patient is usually more concerned with his/ her own needs rather than the feelings of staff C. The patient's physical examination was negative. D. The patient is using the same coping strategy as before, i.e. reliance on a drug to control anxiety. The patient needs to learn alternate methods of coping.

A nurse is planning a community education presentation on domestic violence. Which of the following factors should the nurse include? Instructions on harmonious living with a spouse The telephone number of the local safe house Ways to include the extended family Assertiveness training

The telephone number of the local safe house Explanation: Client Need: Psychosocial Integrity Rationale: B. The telephone number of the local safe house (a place where battered spouses and children may go) would be most useful to the person in a situation of domestic violence. A. Instructions on harmonious living imply that if the abused spouse would just follow these instructions, things would improve. It also implies that he abused spouse is at fault for the abuse and oversimplifies the situation. The abusive spouse will abuse to alleviate his/ her own anxiety, no matter what the abused spouse tries to do make things better. C. Including extended family members can be helpful but this requires the skill and continued support of a qualified therapist. D. Assertiveness training is always a useful skill, but being assertive with an abusive member will many times cause the violence to escalate.

A woman, who is 30 weeks pregnant is attending the prenatal clinic. She has symptoms of pregnancy-induced hypertension. Which of the following findings is indicative of this condition? The woman has been getting shortness of breath when climbing the second flight of stairs to her family's apartment. The woman has a craving for salty foods lately. The woman has a blood pressure of 124/80 mm Hg, compared with 90/60 mm Hg a month ago. The woman has gained three pounds (1.4 kgs) during the past month.

The woman has a blood pressure of 124/80 mm Hg, compared with 90/60 mm Hg a month ago. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. A rise of 30 mm Hg in systolic blood pressure or a diastolic increase of 15 mm Hg is cause for concern by the nurse. These changes are associated with mild preeclampsia. A. Dyspnea is normal as the increasing size of the gravid uterus pushes up on the mother's diaphragm. B. Due to increasing blood pressure, the mother may be craving salty foods but should be cautioned against a high sodium intake. D. A sudden weight gain of four pounds per week or any gain over one pound a week during the second and third trimesters would be of concern to the nurse

Which of the following patient's comment should indicate to the nurse that the patient has ideas of reference? "Those other nurses are talking about me." "The nurse explained how my medication works." "Do all the nurse here have a college degree?" "Will a nurse lead group therapy today?"

Those other nurses are talking about me Explanation: Client Need: Psychosocial Integrity Rationale: A. Patients experiencing ideas of reference frequently misinterpret the messages of others or give meaning to the communications of others. Patients believe that certain events, situations or interactions are directly related to them. B, C and D. None of these patient statements illustrates the concept of ideas of reference. All of the statements are appropriate.

Nursing care for a patient who has polvcthemia vera would focus on preventing: dysrhythmias hypotension thrombosis decubitus ulcers

Thrombosis Explanation: Client Need: Health Promotion and Maintenance Rationale: C. In highly vascular areas, blood flow may become so slow that stasis occurs causing thrombosis in small vessels. A and D. Polycythemia vera has not been documented as a cause of dysrhythmias or decubitus ulcers. B. An increased demand on the pumping action of the heart results in hypertension, not hypotension.

A nurse is assessing a patient who has manifestations of leukemia. Which of the following laboratory results would support this diagnosis? Platelets, 150,000/mm WBC, 150,000/mm Hematocrit, 40% Hemoglobin, 18.0 g/ dL

WBC, 150,000/mm Explanation: Client Need: Safe Effective Care Environment Rationale: B. The WBC count is usually quite high in leukemia. A normal level is 4500- 11,000 mm. A. The platelet count is decreased in leukemia. This is normal count C. In leukemia the hematocrit would be decreased, and this is a normal value D. in leukemia the hemoglobin would be decreased, and not increased.

A nurse caring for a patient from a different culture notices that the patient did not eat the food on the meal tray. Which of the following comments by the nurse demonstrates an understanding of cultural diversity? "What foods do you eat at home?" "You need to eat to keep up your strength." "You will lose weight if you do not eat." "Why didn't you tell me you don't like hospital food?"

What foods do you eat at home? Explanation: Client Need: Safe Effective Care Environment Rationale: A. Inquiring as to the types of food eaten at home shows the nurse's awareness of the patient's cultural and dietary norms. B. This is patronizing response that does not allow for discussion of the problem. C. This response does not provide an opportunity for discussion of eating patterns and food likes and dislikes. D. With this response the nurse assumes that the patient dislikes the food when that may not be the reason that he/ she not eating.

The nurse is assessing a toddler who has an acute upper respiratory infection and notes that the child has been vomiting. The nurse correctly interprets the vomiting as: an indication that the child also has a gastrointestinal infection. a sign that the child is unable to mobilize secretions in the lungs. a common manifestation due to an excessive fluid intake. a common manifestation of respiratory illness in young children.

a common manifestation of respiratory illness in young children. Explanation: Client Need: Physiological Integrity Rationale: D. Vomiting commonly occurs in conjunction with respiratory illness in young children. A. Vomiting in acute respiratory infections does not necessarily mean that the child has a gastrointestinal infection. B. Vomiting is a sign of mobilizing the secretions that children usually swallow. C. Children with respiratory infections often have a poor intake. Drinking too much fluid is an unlikely cause of vomiting in the child.

Test results indicate that the mother is HIV positive. The mother has stated that her choice of infant feeding is breast milk. The postpartum plan of care by the nurse should be based on the knowledge that: breastfeeding should be encouraged for all new mothers to foster maternal child bonding. formula- feeding should be encouraged because the mother is not likely to live long enough to successfully breastfeed the infant. the mother's HIV status should not influence her decision on how to feed her infant. breastfeeding is contraindicated for HIV positive mothers.

breastfeeding is contraindicated for HIV positive mothers. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Transmission of HIV to the fetus or neonate can occur transplacetally and less often by blood and vaginal secretions during delivery and / or via breast milk. A. Breastfeeding would be contraindicated because of the possibility of transmitting the virus through the milk. B. Formula- feeding would be encouraged to prevent transmission of HIV, not because the mother may die. C. The mother should consider her HIV status when deciding whether or not breastfeed her infant.

An adolescent who has sickle cell anemia is planning to go camping. A nurse would advise the child that a crisis might be precipitated by: walking in the woods. fishing in a cold-water stream. canoeing on a lake. cycling up mountain trails.

cycling up mountain trails. Explanation: Client Need: Health Promotion and Maintenance Rationale: D. In sickle cell anemia, the goal is to minimize tissue deoxygenation. The adolescent should be instructed to include frequent rest periods during physical activities, avoid contact sports if the spleen is enlarged, avoid environments for low oxygen concentration, such as high altitudes or non- pressurized airplanes, and avoid known sources of infection. A, B and C. None of these activities are particularly strenuous. The adolescent should be advised to include frequent rest periods when active. The most likely activity to precipitate sickle cell crisis during this vacation is cycling up mountain trails because of the elevation of the mountains.

A nursing assistant tells the charge nurse that another nursing assistant never cleans up the utility room at the end of the shift. The MOST effective approach to resolving the conflict would be to: acknowledge that the nursing assistant who is supposed to clean the utility room may feel overworked. tell the nursing assistant who never helps clean that she needs to help. bring both parties together to discuss underlying issues of conflict. develop a schedule for rotating responsibility for the department's utility room.

develop a schedule for rotating responsibility for the department's utility room. Explanation: Client Need: Safe Effective Care Environment Rationale: C. Bringing both parties together is the most effective strategy for discussing the issues and developing a plan to resolve them. Both parties have an opportunity to express themselves, have the same information from the charge nurse, and can be involved in, and have responsibility for, the resolution. A. This option does not provide resolution of the conflict and may be perceived as taking sides. B. This option puts responsibility for resolving the conflict on the charge nurse, rather than those involved in the situation. D. This solution may resolve the situation for a time, but it does not address the underlying conflict.

A patient does not swallow the medication, but instead hold the tablet in her mouth until she is able to expectorate. The nurse should: discuss with the physician the use of aversion therapy to promote patient compliance. ask the physician for an order to change to an intramuscular form of the medication. discuss with the physician the use of a liquid instead of a tablet. ask the physician for an order to discontinue the medication.

discuss with the physician the use of a liquid instead of a tablet. Explanation: Client Need: Psychosocial Integrity Rationale: C. The patient should be observed when medication is administered to ensure that the drug is swallowed and not held in the patient's cheek and discharged later. Giving a liquid form of the drug makes it much more difficult of the patient to "cheek" the medication. A. Aversion therapy would discourage the patient from taking medication. B. Changing to an intramuscular form of the medication should not be done until other forms, such as liquid, have been tired. D. Other forms of the medication should be tried before considering discontinuation of a medication.

Anurse is caring for a patient on a mechanical ventilator with positive end-expiratory pressure (PEEP). The nurse should recognize that the purpose of this treatment is to: increase pulmonary vascular permeability. increase intrathoracic pressure. improve pulmonary tidal volume. maximize alveolar gas diffusion.

maximize alveolar gas diffusion. Explanation: Client Need: Physiological Integrity Rationale: D. The need for PEEP indicates a severe gas exchange disturbance. PEEP prevents alveoli from collapsing; the lungs are kept partially inflated so that alveolar capillary gas exchanges is facilitated throughout the ventilatory cycle. A. Pulmonary vascular permeability is the problems in ARDS B. Mechanical ventilation is not used for this purpose in ARDS C. Lower tidal volumes may help to decrease peak airway pressure, thus decreasing the risk of barotraumas.

A 16-year-old female who has cystic fibrosis and is sexually active asks a nurse, "Can I get pregnant?" The nurse's response would be based on the understanding that cystic fibrosis: causes sterility in females. leads to a higher incidence of spontaneous abortion. may result in problems with infertility in females. does not affect the reproductive system.

may result in problems with infertility in females. Explanation: Client Need: Physiological Integrity Rationale: C. Women with cystic fibrosis may have lessened fertility from the inability of sperm to migrate through viscid cervical mucus. Other reasons for possible infertility are malnutrition and chronic infection. A. Cystic fibrosis affects fertility but does not necessarily cause sterility in females. B. Cystic fibrosis does not necessarily lead to a higher incidence of spontaneous abortion. D. Cystic fibrosis does affect the reproductive system, often causing decreased fertility in female patients.

When taking the history of a patient who has multiple myeloma, a nurse would expect the patient to report which of the following symptoms? Back pain Blurred vision Hair loss Cloudy urine

Back pain Explanation: Client Need: Physiological Integrity Rationale: A. The nurse should assess the patient with multiple myeloma for pathologic fractures of the ribs and weight bearing bones and compression fractures of the spine due to osteoporosis. These may be evidenced by sudden, severe pain usually related to bending or lifting. B, C and D. These options are not identified as clinical manifestations of multiple myeloma.

A patient who is connected to a cardiac monitor develops a heart rate of 40 beats per minute. Which of the following actions should a nurse take FIRST? Establish intravenous access. Call the physician. Check the patient's blood pressure. Position the patient flat in bed.

Check the patient's blood pressure. Explanation: Client Need: Safe Effective Care Environment Rationale: C. A patient may be bradycardic and asymptomatic, but treatment is necessary if the patient has symptoms such as hypotension. The patient should be assessed before any treatment modalities are instituted. A, B and D. The patient should be assessed for signs of intolerance to the bradycardia, such as dizziness, chest pain or hypotension. Prior to initiating any action.

Which of the following outcomes as observed by the nurse during the drain cycle of peritoneal dialysis should be reported immediately to the physician? Clear yellow output Cloudy output Patient complains of slight cramping A drain output of 50 cc less than instilled

Cloudy output Explanation: Client Need: Physiological Integrity Rationale: B. The return of cloudy dialysate fluid usually indicates the presence of infection. Them nurse should take the patient's vital sighs to determine if the patient has temperature and notify the physician. A. Clear vellow output is a normal finding and would not need to be reported to the physician immediately. C. The patient may experience some slights cramping due to the pressure of the dialysis solution D. Output does not always equal input on every dialysis exchange. The overall pattern of instillation and output should be assessed. A drainage output of 50 cc's less than installed is not unusual.

A nurse observes that a colleague performing an GCS assessment to a child who has a head injury. Which of the following assessment findings performed by the colleague requires ADDITIONAL instruction regarding the use of this scale? Motor response Deep tendon reflexes Verbal ability Eye opening

Deep tendon reflexes Explanation: Client Need: Safe Effective Care Environment Rationale: B. The Glasgow coma scale consist of the three- part assessment including best verbal response, best motor response and eye- opening ability. Deep tendon reflexes are not part of this assessment. The nurse should instruct the colleague in proper use of the scale. A, C and D. Assessment of motor response, verbal ability and eye-opening ability indicates correct use of the scale.

Which of the following food choices should be removed from the dietary tray of a patient who has hepatic encephalopathy? Pasta Spinach Fresh fruit Eggs

Eggs Explanation: Client Need: Physiological Integrity Rationale: D. Patients with hepatic encephalopathy are on a very low protein or no- protein diet. Foods high in protein, such as eggs, need to be restricted. A, B and C. Pasta without meat sauce, spinach and fresh fruit are acceptable food choices for the patient with hepatic encephalopathy.

Which of the following findings would a nurse identify as indicative of septic shock? Bradvcardia Flushed appearance Cool, clammy skin S3 gallop

Flushed appearance Explanation: Client Need: Physiological Integrity Rationale: B. Warm, flushed skin is an integumentary finding of septic shock. A. Tachycardia, rather than bradycardia, is a cardiovascular finding of septic shock C. Cool, clammy skin is found in hypovolemic shock D. No murmur or gallop is auscultated during septic shock.

A nurse teaches self-care management to a teenaged patient who is being treated for scoliosis using a Milwaukee brace. Which of the following statements made by the patient indicates understanding of the nurse's instructions? "I can swim for one hour without the brace." "I must wear the brace over my jacket." " can remove the brace for sleeping." "I must give up driving my car."

I can swim for one hour without the brace Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Swimming strengthens muscles. The brace can be removed for one hour each day for swimming. B. The brace can be worn over a tee-shirt only. C. The brace must be worn for 23 hours a day, seven days a week. D There is no indication that driving a car is contraindicated when wearing the brace.

Which of the following manifestations would a nurse expect when assessing a patient who has atrial fibrillation? Pounding headache Visual disturbances Irregular radial pulse Elevated blood pressure

Irregular radial pulse Explanation: Client Need: Physiological Integrity Rationale: C. Atrial fibrillation is characterized by an irregular atrial and ventricular rhythm. A and B. A pounding headache and visual disturbances are not manifestations of atrial fibrillation. D. Low, rather than high, blood pressure would be observed in atrial fibrillation.

The nurse should instruct a patient who is to receive digoxin (Lanoxin) to report the development of which of the following adverse effects? Ringing in the ears Loss of appetite Signs of bruising Sensitivity to sunlight

Loss of appetite Explanation: Client Need: Safe Effective Care Environment Rationale: B. The dose of digoxin should be withheld and the doctor notified if the patient's pulse if <60 or> 110, or if the patient experiences anorexia, nausea, vomiting, sudden weight gain or edema. Blurred vision and seeing green or yellow halos around objects should be reported. A. Ringing in the ears is an adverse effect of Aspirin therapy and aminoglycoside antibiotics. C and D. Bruising and sensitivity to sunlight are not included in the adverse effects of digoxin.

When assessing a 14-year-old girl who has mittelschmerz, a nurse would expect the girl to have which of the following symptoms? Nausea and vomiting Heavy menstrual flow Low- grade fever and malaise Lower abdominal pain

Lower abdominal pain Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Some women experience a localized lower abdominal pain called mittelschmerz that coincides with ovulation. A, B and C. Nausea, vomiting, heavy menstrual flow, low grade fever and malaise are not indicative of mittelschmerz.

A physician has written all of the following orders for a patient who has a diagnosis of septic shock. Which order should the nurse carry out FIRST? Obtain culture specimens. Initiate antibiotic therapy. Insert indwelling urinary (Foley) catheter. Apply antiembolism stockings.

Obtain culture specimens Explanation: Client Need: Safe Effective Care Environment Rationale: A. Septic shock can be caused by any microorganism. Obtaining specimens for culture should be done prior to the administration of antibiotic therapv. B. After obtaining a culture, antibiotic therapy is usually instituted. C and D. A Foley catheter and anti-embolism stockings are not indicated in the treatment of septic shock.

When planning preoperative care for a child suspected of having Wilms tumor, the nurse should recognize that which of the following interventions places the child at risk for complications? Palpating the child's abdomen every eight hours. Measuring the child's temperature rectally. Monitoring the child's blood pressure ever four hours. Monitoring the child's intake and outout.

Palpating the child's abdomen every eight hours Explanation: Client Need: Physiological Integrity Rationale: A. Wilms tumor, or neuroblastoma, is the most frequent intra-abdominal tumor of childhood and the most common type of cancer. Preoperatively it is important that thetumor is not palpated unless absolutely necessary, since manipulation of the tumor may case dissemination of cancer cell so to adjacent and distal sites. B and D. Preoperative care includes temperature monitoring and intake and output measurement. C. The child's blood pressure is assessed more frequently since hypertension from excess renin production in the kidney is a possibility.

A six-week old infant who has complex congenital heart defect is hospitalized and awaiting surgery. The infant experiences a hypercyanotic episode. Which of the following actions would the nurse take FIRST? Suction the infant. Place infant in knee-chest position. Hyperextend the infant's neck. Take a pulse oximetry reading on the infant.

Place infant in knee-chest position. Explanation: Client Need: Health Promotion and Maintenance Rationale: B. Hypercyanotic spells, also called "blue" or "tet" spells are seen in infants with tetralogy of Fallot prior to surgical repair. The infant becomes acutely cyanotic and hyperpneic because sudden infundibular spasm decreases pulmonary blood flow and increases right to left shunting. Putting the child in knee-chest position reduces the right to left shunting. Oxygen may also be administered. A and C. Suctioning and hyper extending the infant's neck would not be done first. D. The infant's oxygen saturation level may be checked, but he infant is first placed in knee-chest position.

A nurse would recognize that adolescents perceive which of the following issues as being a priority? Nutrition Safety Education Privacy

Privacy Explanation: Client Need: Safe Effective Care Environment Rationale: D. Boundaries around confidentiality and privacy should be established a the beginning of the interview so that adolescents feel that they can discuss sensitive topics. Ensuring confidentiality is one of the most essential ingredients for establishing a trusting relationship. This is particularly essential in sensitive situations such as those involving substances use, sexual concerns or abuse. A, B and C. Nutrition, safety and education may be of interest to adolescents but are not the primary concerns.

Which of the following nursing interventions would the nurse PRIORITIZE when caring for a patient with septic shock? Initiating a bowel program. Encouraging deep breathing. Increasing sensory stimulation. Promoting adequate fluid intake.

Promoting adequate fluid intake. Explanation: Client Need: Safe Effective Care Environment Rationale: D. Interventions for patients experiencing septic shock include correcting the conditions contributing to the shock, and preventing complications. Increasing IV fluid will help to control the fluid volume deficit associated with septic shock. A, B and C. There is no indication that these measures are a priority in the care of a patient with septic shock.

A nurse is counseling the parent of a six-month-old infant about beginning solid foods in the infant's diet. Which of the following food choices should the nurse recommend be introduced initially? Poached egg Strained peaches Pureed peas Rice cereal

Rice cereal Explanation: Client Need: Health Promotion and Maintenance Rationale: D. Rice cereal is usually introduced first, at five to six months of age, because of its low allergenic potential. Wheat products should be avoided for the first 12 months of life. A. Poached eggs would be introduced between eight and 12 months of age, as would plain, low fat yogurt and meat. B. Strained peaches would be introduced between seven and 12 months of age. C. Strained vegetables would be introduced between six and 12 months of age.

To which of the following nursing diagnoses would a nurse PRIORITIZE for a patient whose blood test reveals a white blood cell count of 3000 cells/mm3? Risk for activity intolerance Impaired gas exchange Impaired tissue integrity Risk for infection Explanation: Client Need: Safe Effective Care Environment Rationale: D. The decrease in white blood cells (leukopenia) places the patient at risk for infection. The white blood cells are the first line of defense against invading organisms. A. Risk for activity intolerance is usually associated with a decrease in red blood cells. B. Impaired gas exchange is seen in respiratory disorders such as pneumonia. C. Impaired tissue integrity is seen in decreased perfusion of tissues.

Risk for infection Explanation: Client Need: Safe Effective Care Environment Rationale: D. The decrease in white blood cells (leukopenia) places the patient at risk for infection. The white blood cells are the first line of defense against invading organisms. A. Risk for activity intolerance is usually associated with a decrease in red blood cells. B. Impaired gas exchange is seen in respiratory disorders such as pneumonia. C. Impaired tissue integrity is seen in decreased perfusion of tissues.

A child who has sickle cell disease should eat food sources rich in folic acid. Which of the following food selection would a nurse encourage the child to eat? Peas Spinach Squash Carrots

Spinach Explanation: Client Need: Psychosocial Integrity Rationale: B. The main sources of folic acid are green, leafy vegetables. This includes vegetables such as spinach, broccoli, kale and turnip, mustard, collard, dandelion and beet greens. A, C and D. Peas, squash and carrots are not primary sources of folic acid.

Which of the following nursing actions should be carried out FIRST when a patient requires tracheostomy care? Cleansing around the tracheostomy tube stoma. Deflating the tracheostomy tube cuff. Removing the inner cannula from the tracheostomy. Suctioning the tracheostomy tube.

Suctioning the tracheostomy tube. Explanation: Client Need: Safe Effective Care Environment Rationale: D. Tracheostomy care is initiated with suctioning of the tracheostomy tube, as needed. A and C. Cleansing around the stoma is done after suctioning and cleansing of the inner cannula B. The tracheostomy tube cuff should not deflated in order to prevent expulsion of the tube

A 30-year-old primigravida at 38 weeks gestation in labor is admitted to the hospital. The woman and her husband both attended education-for-childbirth classes. In the labor room, the husband is monitoring the frequency of his wife's contractions. If he is monitoring the frequency accurately, he is noting the time from: the beginning of one contraction to the beginning of the next contraction. the beginning of one contraction to the end of that contraction. the end of one contraction to the beginning of the next contraction. the end of one contraction to the peak of the next contraction.

the beginning of one contraction to the beginning of the next contraction. Explanation: Client Need: Health Promotion and Maintenance Rationale: A. Contractions are timed from the beginning of one contraction to the beginning of the next contraction. B. It describes the duration of the contraction. C. It describes the interval of the contraction. D. It describes the intensity of the contraction.

A patient who has peptic ulcer disease is receiving sucralfate (Carafate). The nurse should instruct the patient to take the medication: one hour after meals. only at bedtime. with meals. up to one hour before meals.

up to one hour before meals. Explanation: Client Need: Physiological Integrity Rationale: D. Carafate should be administered on an empty stomach, one hour before meals and at bedtime. A, B and C. Carafate is changed by stomach acid into a viscous material that binds to proteins in ulcerated tissue. This protects ulcers from the destructive action of the digestive enzyme pepsin. Carafate does not neutralize stomach acid, nor does it inhibit acid secretion. It should be given before meal time so that it can be activated by stomach acid and coat the ulcer.

A child has just undergone a shunting procedure for hydrocephalus. A nurse would question the admission of which of the following patients in the child's room? A child who has acute glomerulonephritis A child who has viral pneumonia A child who has infantile eczema A child who has undergone an appendectomy

A child who has viral pneumonia Explanation: Client Need: Safe Effective Care Environment Rationale: B. Developing infection is the greatest hazard following a shunting procedure. The nurse should be on the alert for potential sources of infection. The patient with a shunt should not be place with a patient who has viral pneumonia. A, C and D. Patients with acute glomerulonephritis and infantile eczema and patients who have undergone an appendectomy do not pose a threat to the patient with a shunt.

Which of the following comments by the spouse of alcoholic patient indicates understanding of the term "blackouts" as applied to alcoholism? "My spouse only drinks after work." "My spouse drinking causes him to forget some event." "My spouse becomes angry when he's drinking." "My spouse's employer doesn't know he drinks."

"My spouse drinking causes him to forget some event." Explanation: Client Need: Psychosocial Integrity Rationale: B. Blackouts are an early symptom of alcoholism. They are defined as amnesia for short-term memories while remote memory stays intact. For example, after a night of drinking with friends, and individual cannot remember how he/ she to home the night before. A, C and D. None of these responses is a description of blackouts.

An elderly widow has dementia of Alzheimer type. While the nurse offers her breakfast, the elderly verbalizes "Oh no, honey. I have to wait until my husband gets here." Which statement by the nurse would be therapeutic? "Your husband died six year ago. Let me put milk on your cereal for you." 'I've told you several times that your husband is dead. It's time to eat now." "You're going to have to wait a long time. Your food will get cold." "Why do you think he's alive? Why can't you just eat your breakfast?"

"Your husband died six year ago. Let me put milk on your cereal for you." Explanation: Client Need: Psychosocial Integrity Rationale: A. The nurse should orient the patient to reality by reminding the patient that her husband died six years ago. The nurse should then move on to the activity at hand. B. This response is harsh. The patient should be told when events occurred, not just that they happened. C. This response does not present an accurate picture of reality and is not appropriate. D. The patient should not be asked for an explanation but should be reminded that her spouse died six years ago.

An infant has a temperature of 104 OF (40.0 C) which of the following interventions would be MOST effective in reducing the infant's temperature? Placing the infant on a cooling blanket. Putting the infant in a tub of tepid water. Administering the prescribed antipyretic to the infant. Sponging the infant with alcohol.

Administering the prescribed antipyretic to the infant. Explanation: Client Need: Physiological Integrity Rationale: C. Relief measure include pharmacological and/ or environmental intervention, the most effective of which is the use of antipyretics to lower the set point. A and B. Traditional cooling measures, such as minimum clothing, exposure of the skin to air, reduction of room temperature, increase air circulation and cool moist compresses to the skin, re effective if employed about one hour after the antipyretic is given so that the set point is lowered. D. Isopropyl alcohol should never be used for sponging. Neurotoxic effect such as stupor, coma and even death have been reported

When admitting a four-day-old Hispanic infant to the pediatric unit, the nurse notes irregular bluish discoloration over the infant's sacrum and buttocks. The nurse should recognize that this is a: sign of child abuse and is reportable. manifestation of a rare bleeding disorder. normal variation in the skin assessment of a newborn. result of a traumatic birth injury.

normal variation in the skin assessment of a newborn. Explanation: Client Need: Health Promotion and Maintenance Rationale: C. Irregular bluish discoloration over the infant's sacrum and buttocks is normal in dark-skinned infants. It is called the Mongolian spot. A. Mongolian spots are normal in dark- skinned infants and are not a sign of child abuse. B. Mongolian spots are normal and not the manifestation of a bleeding disorder. D. Mongolian spots are not the result of a traumatic birth injury.

Which of the following statements made by a 44-year-old female would support a nursing diagnosis of knowledge deficit: early detection of breast cancer? "I should not examine my breasts or have mammogram during my menstrual period." "I include the underarm area when I examine my breasts.' "Women who practice regular breast self-examination find breast lumps earlier than women who do not." "Breast self- examination is not necessary if I get regular mammograms."

"Breast self- examination is not necessary if I get regular mammograms." Explanation: Client Need: Health Promotion and maintenance Rationale: D. Current guidelines include breast self- examination (BSE) starting at age 20; physical examination of the breasts by a trained professional every three years during ages 20 to 40 and every year thereafter; and screening mammography ages 40 to 49 every one to two years, and annually thereafter. A. The best time for pre-menopausal women to examine their breasts in seven days after the start of menstruation. B. The entire breast, axilla and clavicle should be examined. C. Approximately 90 percent of palpable lesions in the breast are found by the woman herself while doing BSE.

A nurse is caring for a patient who has just had an endotracheal tube inserted. Which of the following actions would the nurse take FIRST? Inflate the cuff with appropriate volume. Auscultate for bilateral breath sounds. Tape the tube securely in place. Suction for pulmonary secretions.

Auscultate for bilateral breath sounds. Explanation: Client Need: Physiological Integrity Rationale: B. Immediately after an endotracheal tube is inserted, its placement must be verified. This is done by assessing for bilateral, equal breath sounds. A, C and D. Assessment of endotracheal tube placement must be done immediately following insertion of the tube. All other actions would be done once placement is confirmed.

A patient has been administered with procainamide hydrochloride (Procan SR). Which of the following findings would indicate that the patient is experiencing an adverse effect of the medication? Butterfly rash on the face Blurring of visual fields Dryness of the mouth Ringing in the ears

Butterfly rash on the face Explanation: Client Need: Physiological Integrity Rationale: A. Development of a butterfly rash is an adverse effect to procainamide administration. B, C and D. Hypotension, decreased cardiac output, gastrointestinal distress, allergy, ventricular tachycardia and a lupus- like syndrome are adverse effects of Procan SR. Blurring of visual fields, dryness of the mouth and ringing in the ears are not side effects of the drug.

A nurse would assess a patient who has peripheral vascular disease of which of the following signs associated with venous insufficiency? Paresthesias Bounding pedal pulses Intermittent claudication Edematous ankles

Edematous ankles Explanation: Client Need: Physiological Integrity Rationale: D. There is moderate to severe edema in venous insufficienc. The patient would exhibit edema of the ankles. A. There is an aching, cramping type of pain in venous insufficiency. Paresthesias are present in arterial insufficiency. B. Bounding pedal pulses are not identified as an manifestation of venous insufficiency. They indicate good arterial blood flow. C. Intermittent claudication is a manifestation of arterial insufficiency

Which of these findings should a nurse expect to identify when assessing a patient who is receiving radiation therapy for the treatment esophageal cancer? Peripheral neuropathy Gingival hyperplasia Alopecia Hypersalivation

Hypersalivation Explanation: Client Need: Physiological Integrity Rationale: D. Side effects of radiation to the upper and middle thirds of the esophagus include retrosternal discomfort, pain on swallowing, increased salivation and nausea. A, B and C. Peripheral neuropathy, gingival hyperplasia and alopecia are not side effects of radiation to the esophagus.

A client is being discharged following a lumbar laminectomy. Which of the following client statements would indicate an understanding of the discharge instructions? Your Answer: & Incorrect "I will clean my incision daily with peroxide." "I will only sit for short periods of time." "I will eat foods that are low in fiber." "I will wear an abdominal binder for support."

I will only sit for short periods of time Explanation: Client Need: Physiological Integrity Rationale: B. Prolonged sitting or standing should be avoided by a patient who had a lumbar laminectomy A. The wound does not need daily cleansing with peroxide C. The patient should eat a well-balanced diet. D. An abdominal binder is required post-laminectomy

Which of the following parameters should be given PRIORITY when caring for a patient with hypoadrenalism (Addison's disease)? Evaluating pulmonary function. Monitoring blood sugar. Measuring blood pressure. Assessing neurological status. Explanation: Client Need: Physiological Integrity Rationale: C. Careful monitoring of the patient's reported symptoms, vital signs, weight and fluid and electrolyte balance is essential to determine the patient's progress and return to a pre-crisis state. A and D. These nursing measures are not a priority when caring for a patient with Addison's disease. B. Hyperglycemia is found in hyperadrenalism (Cushing's syndrome).

Measuring blood pressure. Explanation: Client Need: Physiological Integrity Rationale: C. Careful monitoring of the patient's reported symptoms, vital signs, weight and fluid and electrolyte balance is essential to determine the patient's progress and return to a pre-crisis state. A and D. These nursing measures are not a priority when caring for a patient with Addison's disease. B. Hyperglycemia is found in hyperadrenalism (Cushing's syndrome).

A seven-year-old girl is to begin her first immunization schedule. According to recommended guidelines, which of the following vaccines is NOT necessary? Polio Measles Pertussis Mumps

Pertussis Explanation: Client Need: Safe Effective Care Environment Rationale: C. Pertussis vaccine is not given to children seven years of age or older because the risk related to receiving the vaccine increases as the incidence, severity and fatality of the disease decrease. A, B and D. Polio, measles and mumps vaccines are appropriate.

Which of the following nursing measures would be MOST APPROPRIATE in the care of a patient who has acute epistaxis? Tilt the patient's head back. Place the patient's head between his legs. Pinch the nose and have the patient lean forward. Place warm compresses on the patient's nasal bridge.

Pinch the nose and have the patient lean forward. Explanation: Client Need: Physiological Integrity Rationale: C. Initial treatment of epistaxis includes applying direct pressure by pinching the soft, outer portion of the nose against the midline septum. A and B. The patient should sit with the head tilted forward to prevent aspiration. D. Ice or cool compresses can be applied to the face the nose. If bleeding is from the anterior nasal cavity, then anterior packing is used in treatment.

A patient who has disseminated intravascular coagulation (DIC) is administered with heparin sodium. Which of the following patient responses would indicate that heparin is effective? Breath sounds are clear upon auscultation. Stools are negative for occult blood. Pupils are equal and reactive to light. Oral mucosa is pink and moist.

Stools are negative for occult blood. Explanation: Client Need: Physiological Integrity Rationale: B. Indications of effective treatment with heparin are a return of clotting test to normal and decrease in hemorrhagic manifestations. Stools negative for occult blood is an indication of effectiveness of treatment. A, C and D. Clear breath sounds, pupils equal and reactive to light and pink, moist mucous membranes are not indicators of the effectiveness of heparin therapy.