Question Trainer 3

The client is receiving imipramine. It is most important for the nurse to instruct the client to immediately report which symptoms? Select all that apply. 1. Fever. 2. Dry mouth. 3. Increased fatigue. 4. Vomiting and diarrhea. 5. Staggering gait. 6. Sore throat.

- Fever= TCA and hyperthermia can be side effect - Dry mouth= TCA and dry mouth side effect - Increased fatigue= TCA and increased fatigue side effect - Vomiting and Diarrhea= TCA and N/V/D side effects - Sore throat= TCA and sore throat side effect

The nurse receives report from the previous shift. In which order should the nurse see these clients? Place the answers in order of priority. All options must be used. The client 1 day postoperative with an epidural catheter in place. The client diagnosed with cardiomyopathy being evaluated for a heart transplant. The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400. The client post coronary artery bypass graft having the atrioventricular wires removed at 1500.

1. Pt 1 day post op with postop epidural catheter in place= needs assessment for side effects of epidural and is fresh postop respiratory consideration 2. Pt diagnosed with cardiomyopathy being evaluated for a heart transplant= unstable, requires monitoring and early assessment; circulation consideration 3. Pt diagnosed with type 1 diabetes scheduled for cardiac catheterization at 1400= need assessment of blood glucose and preop needs but falls behind respiratory and circulation 4. Pt post coronary artery bypass graft having AV wires removed at 1500= stable

The nurse receives report on these clients from the previous shift. In which order should the nurse see the clients? Place the answer in order of priority. All options must be used. 1. The client receiving ciprofloxacin IV, reports a fine macular rash on the chest. 2. The client receiving a blood transfusion who reports a dry mouth. 3. The client receiving IV potassium infusion who reports burning at the IV site. 4. The client scheduled to receive heparin and the aPTT is 70 seconds.

1. The client receiving ciprofloxacin IV, reports a fine macular rash on the chest= indicates hypersensitivity reaction; should stop med and notify HCP 2. The client receiving IV potassium infusion who reports burning at the IV site= should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires first attention 3. The client scheduled to receive heparin and the aPTT is 70 seconds= lower limit of normal is 20-25 sec; upper limit of normal is 32-39 sec; aPTT is within therapeutic range; therapeutic levels increase aPTT 1.5 to 2 times control value; should give med 4. The client receiving a blood transfusion who reports a dry mouth = not an immediate concern; routine transfusion eval

The nurse responds to a train derailment. After making initial assessments, in what order should the nurse see these clients? Place the answers in order of priority. All options must be used. The young client with blood pulsating from a cut on the right leg. The pregnant client who states clothing is wet. The unconscious client with the right leg shorter than the left leg. The preschool child who is screaming and crying uncontrollably.

1. Young pt with blood pulsating from a cut on right leg= indicates arterial bleeding; apply direct pressure; high risk for shock 2. Unconscious pt with right leg shorter than left leg= possible hip fracture, no indication of resp difficulty; client unconscious, may have other problems 3. Pregnant client who states clothing is wet= requires further assessment, could be amniotic fluid or urine!! 4. Preschool child who is screaming and crying uncontrollably= stable pt, no indication of injuries

The client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which nursing assessment finding supports this diagnosis? Select all that apply. 1. Buffalo hump. 2. Intolerance to heat. 3. Hyperglycemia. 4. Hypernatremia. 5. Intolerance to cold. 6. Irritability

CORRECT: - Buffalo hump= hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections - Hyperglycemia - Hypernatremia INCORRECT: - Intolerance to heat= hyperthyroidism - Intolerance to cold= hypothyroidism - Irritability= hypothyroidism

The nurse plans a diet for the child diagnosed with cystic fibrosis (CF). Which dietary requirements are considered by the nurse? Select all that apply. 1. High-protein. 2. Low-sodium. 3. High-calorie. 4. Low-protein. 5. Low-carbohydrate. 6. High-sodium.

CORRECT: - High protein= impaired intestinal absorption due to CF necessitates a diet high in protein and calories - High calorie INCORRECT: - Low sodium= no need to reduce sodium - Low carbohydrate= level of carbs is not as important as increased calories BOOK NOTES: Cystic fibrosis (pg, 167, - Absence of pancreatic enzymes leads to malabsorption of fat and fat soluble vitamins - Infection and lung disease lead to increased need for cals and protein

The client is admitted for regulation of insulin dosage. The client takes 15 units of isophane insulin at 08:00 every day. At 16:00, which nursing observations indicate a complication from the insulin? Select all that apply. 1. Acetone odor to the breath. 2. Irritability. 3. Polyuria. 4. Tachycardia. 5. Headache. 6. Diaphoresis.

CORRECT: - Irritability - Tachycardia - Diaphoresis Isophane insulin is an intermediate acting insulin that peaks form 8 to 12 hours after admin; this is when signs and symptoms of hypoglycemia occur INCORRECT: - Acetone odor to breath= hyperglycemia - Polyuria= hyperglycemia - Headache= hyperglycemia

The nurse cares for a client with a diagnosis of Guillain-Barré syndrome. Which symptoms support this diagnosis? Select all that apply. 1. Respiratory failure. 2. Pulmonary congestion. 3. Hypertension. 4. Flaccid paralysis. 5. Hemiplegia. 6. Urinary retention.

CORRECT: - Respiratory failure= classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation. - Flaccid paralysis - Urinary retention INCORRECT: - Pulmonary congestion - Hypertension= may have hypotension - Hemiplegia= paralysis is whole body not one sided as in CVA BOOK NOTES: Guillain Barre Syndrome (pg, 157-158) - Parathesias, pain often occurring in glove and stocking distribution - Motor loss symmetrical, usually beginning in lower extremities, then extend upward - Respiratory muscle compromise, DTR disappear - Excessive or inadequate autonomic dysfunction= hypotension, tachycardia, vasomotor flushing, paralytic ileus, profuse sweating - Plateau period= progresses to peak severity between 2 to 4 weeks, avg 10 days - Recovery period= several months to a year, 10% residual disability - Progressive inflamm autoimmune response occurring in peripheral nervous system resulting in compression of nerve roots and peripheral nerves and demyelination occurs and slows/alters nerve conduction - Possible causes= infection, viral, autoimmune, may follow immunizations - Acute rapidly ascending sensory and motor deficit that may stop at any level of the CNS

The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. In which order does the nurse address these situations? Place the answers in order of priority starting with the first client to be seen. All options must be used. The client diagnosed with depression says to the nurse, "My plan is complete, and I'm ready to go." The client diagnosed with bipolar disorder walks into the day room wearing only underwear. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed. The client with substance abuse reports harassment by another client.

CORRECT: 1. The client diagnosed with depression says to the nurse, "My plan is complete, and I'm ready to go." = could indicate impending suicide; requires immediate follow-up 2. The client with substance abuse reports harassment by another client= should be removed to quiet area, decrease environmental stimuli; may cause distraction for other clients 3. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed= experiencing command hallucination; protect from injury and destroying the TV 4. The client diagnosed with bipolar disorder walks into the day room wearing only underwear= not a harm to self or others

The client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented 2. The client will be unable to maintain any oral intake as long as the tracheotomy is in place 3. Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration 4. Because the client is dependent on the ventilator, nutritional intake will be delayed

CORRECT: 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented í tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area INCORRECT: - client will be unable to maintain any oral intake as long as the tracheotomy is in place í pt will be able to eat normally after area has healed - Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration í nutritional intake will begin when bowel sounds return and pt can tolerate intake

The client with newly diagnosed type 1 diabetes says to the nurse, "I know I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which response by the nurse is best? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half-size larger than your foot size so the fit is roomy." 4. "Buy vinyl shoes because they won't lose their shape easily."

CORRECT: "2 Have each foot measured every time you buy new shoes." - feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger) INCORRECT: It is best to buy new shoes in the morning - Buy shoes in the afternoon when feet are larger than in the morning

The 8-year-old has been receiving chemotherapy for 6 months. The child asks, "Am I going to die?" Which response by the nurse is best? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."

CORRECT: "Are you afraid of dying?" - Encourages ventilation of thoughts and feelings regarding the concern INCORRECT: "Why do you ask that question?" - Inappropriate

The office nurse reinforces the health care provider's explanation for a myelogram. Which statement correctly describes a myelogram for the client? 1. "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2. "The test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4. "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."

CORRECT: "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." - Contrast medium is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, herniated vertebral disks INCORRECT: - The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown= X ray can't determine extent of myelin breakdown - The test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk= does not exist, injecting contrast medium into a ruptured disk would not allow visualization of the spinal column

The nurse cares for the male client diagnosed with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. Which statement best describes the rationale for doing these tests? 1. These tests are valuable screening tests for prostatic cancer. 2. The level of PSA is decreased in clients with renal calculi. 3. The tests reflect the level of renal involvement in acid-base problems. 4. The level of PSA is elevated in clients in early-stage kidney failure.

CORRECT: 1 These tests are valuable screening tests for prostatic cancer. - PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value

The child has a closed transverse fracture of the right ulna. Which nursing action before the application of a cast is most important? 1. Check the radial pulses bilaterally and compare. 2. Evaluate the skin temperature and tissue turgor in the area. 3. Assess sensation of each foot while the child closes the eyes. 4. Apply baby powder to decrease skin irritation under the cast.

CORRECT: 1 check radial pulses and compare --> assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulsessness INCORRECT: apply baby powder to decrease skin irritation under the cast --> should not be done because would INCREASE skin irritation

The parent of the 7-year-old child is dying. The nurse anticipates the child will have which concept of death? 1. Death is punishment for the child's actions. 2. Death is inevitable and irreversible. 3. Death is temporary and gradual. 4. Death as a concept based on past experience.

CORRECT: 1. Death is punishment for childs actions INCORRECT: - Death inevitable and irreversible= by age 9, most kids begin to develop an adult concept of death and begin to understand death is irreversible - Death temporary and gradual= preschool child concept - Death concept based on past experience= adolescent concept

The nurse assists a nursing assistive personnel (NAP) in providing a bed bath to the comatose client with incontinence. The nurse intervenes if which action is noted? 1. The NAP answers the phone while wearing gloves 2. The NAP log rolls the client to provide back care 3. The NAP places an incontinence pad under the client 4. The NAP positions the client on the left side, head elevated

CORRECT: 1. The NAP answers the phone while wearing gloves --> contaminated gloves should be removed before answering the phone INCORRECT: NAP positions the pt on the left side, head elevated --> appropriate position to prevent aspiration and protect the airway

The client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client is diagnosed with a spinal cord injury at the level of C4. The client is tearful, constantly reports discomfort, and requests to be suctioned. The nurse understands the client's attention-seeking behaviors may be due to which feelings? 1. Anger and frustration. 2. Awareness of vulnerability. 3. Increased social isolation. 4. Increased sensory stimulation.

CORRECT: 2 Awareness of vulnerability - experiencing an increased awareness of physical vulnerability due to the spinal cord injury; fosters increased dependency needs that are real due to the injury; is trying to determine who is consistent and trustworthy for meeting significant physical needs

The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool-aged child. After the cast is applied, the nurse takes which action first? 1. Petals the edges of the cast to prevent irritation. 2. Elevates the child's left arm on two pillows. 3. Applies cool, humidified air to dry the cast. 4. Asks the client to move the fingers to maintain mobility.

CORRECT: 2 Elevates the child's left arm on two pillows - Minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast INCORRECT: Asks the client to move the fingers to maintain mobility - maintaining mobility of fingers not most important after application of cast Petals the edges of the cast to prevent irritation - done when cast is completely dry, prevents crumbling of plaster into cast BOOK NOTES: Casting (pg, 350-351) - avoid covering cast until dry (48h or >) handle with palms not fingertips - keep affected limb above heart on soft surface until dry, don't use heat lamp - elevate arm cast above level of heart

The neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Because the infant's mother is diagnosed with type 1 diabetes, the nurse knows the infant is at greatest risk for developing which problem? 1. Hypovolemia. 2. Hypoglycemia. 3. Hyperglycemia. 4. Cold stress.

CORRECT: 2 Hypoglycemia - Fetus produces increased insulin to match mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth = hypoglycemia BOOK NOTES: Diabetes (pg, 496) - Increased Risk For: Maternal infx (UTIs and yeast) - Hypertensive states of pregnancy - Hydramnios - Macrosomia - Congenital anomalies - Prematurity and stillbirth - Respiratory distress syndrome - Untreated ketoacidosis can cause coma and death of mother and fetus

A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the client to make which statement about symptoms? 1. "I have been having difficulty with my hearing." 2. "I lose my balance easily." 3. "I can't tell the difference between a sweet and sour taste." 4. "It is not easy for me to remember names and faces."

CORRECT: 2 I lose my balance easily - Cerebellum maintains balance INCORRECT: - I have been having difficulty with my hearing= temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic - I can't tell the difference between a sweet and sour taste= CN IX, glossopharyngeal responsible for differentiation of taste BOOK NOTES: Cerebellar functioning (pg, 558) - Coordination - Point to point touching - Rapid alternating movements - Gait

The nurse cares for the client one day after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe q 2 h. Which does the nurse understand to be the purpose of this nursing action? 1. Promote ventilation and prevent respiratory acidosis. 2. Increase oxygenation and removal of secretions. 3. Increase pH and facilitate balance of bicarbonate. 4. Prevent respiratory alkalosis by increasing oxygenation.

CORRECT: 2 Promote ventilation and prevent respiratory acidosis. - primary purpose of nursing measure is to improve and or maintain a good gas exchange, especially removal of CO2 in order to prevent respiratory acidosis INCORRECT: Increase oxygenation and removal of secretions - promoting ventilation and preventing respiratory acidosis is better because it refers to ventilation rather than oxygenation

The young adult is immobilized for trauma to the spinal cord. The client has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which is the most important nursing diagnosis? 1. Risk for Constipation related to immobilization. 2. Risk for Impaired Skin Integrity related to immobilization and secretions. 3. Risk for Infection related to involuntary bowel secretions. 4. Risk for Fluid Volume Excess related to secretions.

CORRECT: 2 Risk for impaired skin integrity related to immobilization and secretions --> skin susceptible to breakdown because of immobility and bodily secretions; needs numerous interventions to prevent this

The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg

CORRECT: 2 The client leads with the cane, followed by the right leg and then the left leg. - to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down

The nurse administers Rho(D) immune globulin to prevent complications in which client situation? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

CORRECT: 2 The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs - Rho(D) immune globulin is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test INCORRECT: The mother is Rh-positive and previously sensitized, and the baby is Rh-negative - Med not given if mom has been sensitized by previous pregnancy The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy - No incompatibility because Rh positive mother not at risk for Rh incompatibility, only Rh negative mother with Rh positive fetus BOOK NOTES: Hemolytic Disease (pg, 486, 517) - Coombs test= detects antibodies attached to circulating erythrocytes, performed on cord blood sample - Baby's Rh antigens enter mother, mother produces antibodies, antibodies re enter baby and cause hemolysis and jaundice - Rho(D) immune globulin to mother= Rho (D) promotes lysis of fetal Rh positive RBCs circulating in maternal blood stream before Rh negative mother develops her own antibodies o them

The client is scheduled for electromyography (EMG). Which information does the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be allowed to eat 4 to 6 hours before the procedure."

CORRECT: 2 This is a noninvasive procedure that takes about 30 minutes. - electrodes are attached to muscles, length of time for impulse transmission is measured INCORRECT: Your hair will be carefully washed prior to the procedure - performed on selected muscles, usually of the extremities

The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for the client. Which result indicates the tube feeding can begin? 1. A small amount of white mucus is aspirated from the NG tube. 2. The contents aspirated from the NG tube have a pH of 3. 3. No bubbles are seen when the nurse inverts the NG tube in water. 4. The client says the NG tube can be felt in the back of the throat

CORRECT: 2 contents aspirated from the NG tube have a pH of 3

The client has a neurologic disorder. Which nursing assessment is most helpful to determine subtle changes in the client's level of consciousness? 1. Client posturing 2. GCS 3. Client thinking pattern 4. Occurrence of hallucinations

CORRECT: 2-GCS evaluate eye opening, motor, and verbal responses

The nurse cares for the multipara client who delivered an infant 1 hour ago. The nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2 cm below the umbilicus, and there is moderate lochia rubra. It is most important for the nurse to take which action? 1. Perform a straight catheterization. 2. Offer the client the bedpan. 3. Put the baby to breast. 4. Massage the uterine fundus.

CORRECT: 2. offer the pt a bedpan --> boggy uterus deviated to the RIGHT indicates a full bladder, encourage client to void INCORRECT: Put baby to breast --> will increase uterine tone, but problem is full bladder

The nurse cares for the client after right cataract surgery. The nurse intervenes if which observation is made? 1. Client is in the supine position. 2. The head of the bed is elevated 30 degrees. 3. The client is lying on the right side. 4. An eye shield is over the right eye.

CORRECT: 3 The pt is lying on the right side --> client should not be positioned with operative side in a dependent position or againt the bed INCORRECT: HOB is elevated 30 degrees --> decreases swelling and pain

The client is to have an intravenous pyelogram (IVP). Nursing management includes which action? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime. 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter. 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4. Explaining the importance of following directions regarding voiding during the test.

CORRECT: 3 cleansing enemas the evening before to provide for adequate visualization of the urinary tract - Because of need to visualize abdominal area, cleaning enemas the evening before an IVP usually ordered INCORRECT: Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter - Retention indwelling catheter may be in place but not for the purpose of dilating the bladder sphincter A fat-free meal the evening before the examination and radiopaque tablets at bedtime - Associated with gallbladder series

The nurse in the pediatric office observes the child in the waiting room. The child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1. 1 year old. 2. 2 years old. 3. 3 years old. 4. 5 years old.

CORRECT: 3 years old - Able to jump with both feet and stand on one foot momentarily at 30 months INCORRECT: 2 years old - Unable to jump until 30 months

The nurse prepares a dopamine infusion for the client. Which action does the nurse take first? 1. Evaluates the urine output 2. Obtains the client's weight 3. Determines the patency of the IV line 4. Measures pulmonary artery pressures

CORRECT: 3-Determines the patency of the IV line - if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects

The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the initial priority nursing action? 1. Provide adequate hygiene and nutrition. 2. Decrease environmental stimuli. 3. Slowly involve the client in unit activities. 4. Administer and monitor sedative and mood-stabilizing medications.

CORRECT: 4 Administer and monitor sedative and mood-stabilizing medications - most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents INCORRECT: - Provide adequate hygiene and nutrition = very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority - Decrease environmental stimuli= decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression

The parent of a toddler recovering from surgery is concerned because the client is restless and overactive. Which action will the nurse take? 1. Direct the LPN/LVN to obtain the client's vital signs. 2. Ask the parent if the client's sutures are still intact. 3. Tell nursing assistive personnel to take the client for a walk. 4. Check to see when pain medication was last provided.

CORRECT: 4 Check to see when pain medication was last provided - Young children typically become restless and overactive in response to pain. Grimacing, clenching teeth, rocking, and aggressive behavior may also be observed INCORRECT: Direct the LPN/LVN to obtain the client's vital signs - No indication there are problems in pt VS

The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the most appropriate nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications. 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. 3. Restart the IV and continue the previous medication schedule. 4. Call the health care provider and recommend the IV medication be changed to PO.

CORRECT: 4 call HCP and recommend IV med changed to PO - before new IV started, HCP should be called and PO meds recommended INCORRECT: Apply warm soaks to the infiltration site, start a new IV, and continue IV medications - continued IV meds may not be necessary based on pt improved breathing, IV meds may not be indicated BOOK NOTES: Aminophylline (pg, 105) - bronchodilator/leukotriene-receptor blocker med - AEs: nervousness, nausea, dizzy, tachycardia, seizures - Coffee, tea, cola increase risk of adverse reactions

The nurse cares for the elderly client who is admitted with confusion, mood lability, impaired communication, and lethargy. Which order from the health care provider does the nurse question? 1. Dexamethasone suppression test 2. Thyroid studies 3. Drug toxicology screen 4. Trendelenburg test

CORRECT: 4-Trendelenburg test - test is used with a client who may have varicose veins, which have no relationship to the symptoms described in this situation

The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation most likely indicates bulimia? 1. Edema of the lower extremities 2. The presence of lanugo 3. Dry, yellowish colored skin 4. Ulcerated oral mucous membranes

CORRECT: 4-Ulcerated oral mucous membranes í due to frequent vomiting INCORRECT: Edema of the lower extremities í common with anorexia BOOK NOTES: Bulimia (pg, 601) - Characterized by fear of obesity, dramatic weight loss, distorted body image, very structured food intake - May be normal weight to overweight - Tooth erosion and decay - GI bleeding (upper and lower) - May be managed with antidepressants (SSRIs)

The elderly alcoholic client receives a long-acting benzodiazepine for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which problem? 1. A reaction to the sedative medication. 2. A worsening course of the withdrawal syndrome. 3. An exacerbation of the schizophrenia process. 4. The process of aging and the effects of delirium.

CORRECT: A worsening course of the withdrawal syndrome - pt has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations INCORRECT: - A reaction to the sedative medication= pt has been medicated with benzos and did not experience untoward reactions - The process of aging and the effects of delirium= combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementia

The elderly client diagnosed with chronic schizophrenia is cared for in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation includes which finding? 1. Assessment of ADL (self-care) ability. 2. Mini-Mental Status Examination (MMSE). 3. Abnormal Involuntary Movement Scale (AIMS). 4. Modified Overt Aggression Scale (MOAS).

CORRECT: Abnormal involuntary movement scale (AIMS) - Most widely accepted examination to test for presence of tardive dyskinesia INCORRECT: Modified Overt Aggression Scale (MOAS) - assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population

The nurse cares for the client with dementia. Which plan of care is most successful? 1. Teach new skills for adjusting to the aging process. 2. Adjust the environment to meet the client's individual needs. 3. Encourage competitive activities to keep the client physically strong. 4. Provide unstructured activities with frequent changes to increase stimulation.

CORRECT: Adjust the environment to meet the client's individual needs - client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability INCORRECT: Teach new skills for adjusting to the aging process - unable to learn new skills

The client with bipolar illness is extremely angry. The client tells the nurse, "I just found out my spouse has filed for divorce. I need to use the phone right now!" Which action by the nurse is most appropriate? 1. Allow the client to use the phone. 2. Confront the client about the anger and inappropriate plan of action. 3. Do not allow the client to use the phone because this is an involuntary admission. 4. Set limits on the client's phone use because of the inability to control behavior.

CORRECT: Allow the client to use the phone - Client is able to use the phone unless otherwise indicated by a court order or HCP INCORRECT: Do not allow pt to use the phone because involuntary admission - Denies pt has civil rights

The nurse provides care for a client in a psychiatric facility. The client describes seeing snakes on the walls of the room. Which is an accurate nursing diagnosis? 1. Altered sensory perception. 2. Long-term confusion. 3. Impaired coping. 4. Altered interaction.

CORRECT: Altered sensory perception - reflects a pattern of altered perception, which is supported by the data that the client is having a hallucination, defined as a sensory perception for which no external stimuli exist INCORRECT: Altered interaction - not relevant to data

The client is diagnosed with an obsessive-compulsive ritual. The nurse recognizes the client is attempting to achieve which psychological status? 1. Control of other people. 2. Increased self-esteem. 3. Avoid severe levels of anxiety. 4. Express and manage anxiety.

CORRECT: Avoid severe levels of anxiety - obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so INCORRECT: Express and manage anxiety - not a method of expressing but a strategy to avoid it

The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2° F (39° C) and frequent vomiting. The nurse expects to find which reflex? 1. Babinski reflex. 2. Moro reflex. 3. Tonic neck reflex. 4. Grasp reflex.

CORRECT: Babinski - Stroked outer sole of foot upward causes toe to hyperextend and fan and great toe to dorsiflex; disappears after 1 year!! INCORRECT: - Moro reflex= sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape; disappears after 3 to 4 months!! - Tonic neck reflex= when head it turned to side, arm and leg extend on that side and opposite arm and leg flex; disappears by 3 to 4 months!! - Grasp reflex= touching palms or soles of feet causes flexion of hands and toes; palmar grasp disappears after 3 months and plantar grasp by 8 months!!

The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the health care provider? 1. Headache. 2. Disruption in short- and long-term memory. 3. Transient confusional state. 4. Backache.

CORRECT: Backache - client undergoing ECT needs to be instructed about what could be experienced during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the health care provider INCORRECT: - HA= expected - Disruption in short and long-term memory= expected - Transient confusional state= expected

The client has a three-way indwelling urinary catheter following a transurethral resection. Which finding causes the nurse to infuse the irrigating solution rapidly? 1. The urinary output is increased. 2. Bright-red drainage or clots are present. 3. Dark-brown drainage is present. 4. The client reports pain.

CORRECT: Bright red drainage or clots present - nurse should irrigate three-way urinary catheter rapidly when bright-red drainage or clots are present; nurse should decrease irrigation rate to about 40 gtt/min when the drainage clears INCORRECT: Dark-brown drainage is present - not an indication to infuse rapidly

The nurse observes the student nurse care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity? 1. Gives isoniazid to a client with tuberculosis. 2. Administers an IM injection to a client with rubella. 3. Delivers a food tray to a client with hepatitis. 4. Changes the dressing for a client with a draining abscess.

CORRECT: Changes the dressing for a client with a draining abscess - requires contact precautions INCORRECT: - Administers an IM injection to a client with rubella= DROPLET precautions, nurse should wear a mask - Gives isoniazid to a client with tuberculosis= AIRBORNE, particulate respirator - Delivers a food tray to a client with hepatitis= STANDARD

The client is learning to self-administer insulin. Which observation indicates to the nurse the client needs further teaching? 1. The client draws up the short-acting insulin first, then the intermediate-acting insulin. 2. The client gently rotates the insulin bottle before withdrawing the dose. 3. The client rotates injection sites following the guide on the printed diagram. 4. The client administers the insulin while it is still cold from the refrigerator.

CORRECT: Client administers insulin while it is still cold from the refridgerator. - insulin should be administered at room temperature; temperature extremes should be avoided INCORRECT: - The client draws up the short-acting insulin first, then the intermediate-acting insulin= when mixing short-acting insulin with other types of insulin, the client should draw up the clear (short-acting [regular]) before the cloudy (intermediate-acting)

A newborn client at 32 weeks' gestation weighs 4 lb 10 oz (2.12 kg) and has mottling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect this client is experiencing? 1. Hypoglycemia. 2. Cold stress. 3. Birth asphyxia. 4. Hypovolemia.

CORRECT: Cold stress - Mottling of the skin, acrocyanosis, and irregular respirations at the rate of 60 bpm symptoms of cold stress INCORRECT: Hypoglycemia - Blood glucose level <25 mg/dL; symptoms include cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, and coma

The client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1. Guarantees secure placement of the tracheostomy tube in the airway. 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it. 3. Decreases the chance of aspiration into the trachea. 4. Protects the trachea from ischemia and edema.

CORRECT: Decreases the chance of aspiration into the trachea - Seals trachea, helps to prevent aspiration INCORRECT: Guarantees secure placement of the tracheostomy tube in the airway - Not the purpose Prevents ischemia of the tracheal wall by distributing the pressure applied to it - Complication of using cuffed trach tube

The nurse provides care for a 2-day-old client. The neonate will not take formula from the parent or the nurse. Which is the priority nursing diagnosis? 1. Swallowing difficulty. 2. Failure to thrive. 3. Dehydration. 4. Altered bonding.

CORRECT: Dehydration - Priority is fluid volume for neonate INCORRECT: Failure to thrive - Impaired growth, fluid vol more important

The nurse assesses the client with severe bilateral peripheral edema. Which is the best way for the nurse to determine the degree of edema in a limb? 1. Measure both limbs with the tape measure and compare. 2. Depress the skin and rank the degree of pitting. 3. Describe the swelling in the affected area. 4. Pinch the skin and note how quickly it returns to normal.

CORRECT: Depress the skin and rank the degree of pitting - severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)

The parent brings 10-year-old and 3-year-old children to the pediatric office. The younger child reports dysuria. The health care provider orders a catheterized urine specimen. The nurse takes which action? 1. Describes the procedure to the child in short, concrete terms while talking calmly. 2. Allows the child to play with the equipment during the procedure. 3. Involves the older sibling in explaining the procedure. 4. Shows the child a diagram of the urinary system.

CORRECT: Describes the procedure to the child in short, concrete terms while talking calmly - Children at this age need simple explanations INCORRECT: Allows the child to play with the equipment during the procedure - Might contaminate the equipment, must be a sterile procedure

The nurse observes the fetal heart monitor pattern below for the client in active labor. Which pattern does the nurse identify for this monitor strip? 1. Early Deceleration. 2. Late Deceleration. 3. Variable Deceleration. 4. Decreased Variability.

CORRECT: Early Deceleration - Occurs in response to compression of fetal head, uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress INCORRECT: - Late deceleration= show decreasing fetal heart rates that correspond to the increasing uterine contraction; abnormal finding indicating utero-placental dysfunction - Variable deceleration= rapid in decent and commonly do not correspond to the uterine contraction pattern; found with cord compression. - Decreased Variability= flattening of fetal baseline BOOK NOTES: Decelerations (pg, 480) - Early= onset close to the beginning or before peak of contraction; most often uniform mirror image of contraction on tracing; associated with head compression, in second stage with pushing, reassuring pattern - Late= onset after contraction is established; usually begins at the peak of the contraction, with slow return to baseline after contraction is complete, indicative of FETAL HYPOXIA because of deficient placental perfusion; caused by PIH, maternal diabetes, placenta previa, abruption placentae, nonreassuring sign - Variable= transient U/V shaped reduction occurring at any time during uterine contracting phase; decrease usually more than 15 bpm, lasting 15 seconds, return to baseline in less than 2 minutes from onset, indicative of cord compression, which may be relieved by change in mother's position; ominous if repetitive if prolonged, severe, or slow return to baseline; admin O2, discontinue oxytocin - For late decels= position mother LEFT SIDE LYING, Trendelenburg or knee chest position; admin O2 by mask, start IV or increase flow rate, stop oxytocin if appropriate, prep for C section - Variable= reposition mother left side lying to relieve pressure on umbilical cord

The nurse teaches a health class to a group of senior citizens. Which behavior does the nurse emphasize to facilitate regular bowel elimination? 1. Avoid strenuous activity. 2. Eat more foods with increased bulk. 3. Decrease fluid intake to decrease urinary losses. 4. Use oral laxatives so a bowel pattern emerges.

CORRECT: Eat more foods with increased bulk - fiber contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis INCORRECT: Decrease fluid intake to decrease urinary losses - normal fluid intake of 1,500 mL/day facilitates bowel elimination

A client suspects she is pregnant because the last menstrual period began May 8 and ended May 12. Which estimated date of birth (EDB) will the nurse calculate for this client? 1. February 1. 2. February 15. 3. February 19. 4. March 14.

CORRECT: Feb 15 - When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. For example, May 8 plus 7 days is May 15 minus 3 months is February 15th. INCORRECT: February 19 - February 19 is incorrect using Naegele's rule to determine EDB. When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. This EDB uses the date of the last day, not first day, of the last menstrual cycle.

The client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows which behavior best describes the client's need for repetitive acts of hand-washing? 1. Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2. Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body. 3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. 4. Hand-washing helps maintain the client in an active state to resist the effects of depression.

CORRECT: Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. - Compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the pt is experiencing INCORRECT: Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body - Not accurate statement BOOK NOTES: OCD (pg, 570) - Obsession= repetitive, uncontrollable thoughts - Compulsion= repetitive, uncontrollable acts - Managed with clomipramine, SSRIs - Stimulus-response prevention

The client has orders for cefoxitin 2 g IV piggyback in 100 mL 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is most important for the nurse to take which action? 1. Administer the medication slowly, at 20 to 25 mL/h. 2. Change the primary IV solution. 3. Hang the piggyback infusion bag higher than the primary infusion bag. 4. Obtain an infusion pump prior to administration.

CORRECT: Hang the piggyback infusion bag higher than the primary infusion bag - When using gravity drip, fluid level needs to be higher than primary INCORRECT: Change the primary IV solution - Unnecessary for safe infusion

The nurse assesses the client's neurosensory cerebellar functioning. Which assessment technique is correct? 1. Test the client's deep tendon reflexes to observe for weakness. 2. Check the client's pupils with a penlight and observe for constriction. 3. Have the client stand with eyes closed and observe for swaying. 4. Ask the client to show the teeth and stick out the tongue.

CORRECT: Have the client stand with eyes closed and observe for swaying - Coordination is governed by the cerebellum, this test evaluates neurosensory status INCORRECT: - Test pt DTR to observe for weakness= general central nervous system response, not sensory involvement - Check pt pupils with penlight and observe for constriction= eval intraocular pressure - Ask pt to show the teeth and stick out the tongue= eval facial and hypoglossal nerves

The client is treated in the telemetry unit for cardiac disease. The client receives propranolol hydrochloride 20 mg PO at 09:00. When the nurse enters the room to give the medication to the client, the nurse finds the client wheezing with a nonproductive cough and shortness of breath. Initially the nurse takes which action? 1. Holds the medication and counts the respirations. 2. Holds the medication and calls the health care provider. 3. Takes an apical pulse and then gives the medication. 4. Gives the mediation as ordered.

CORRECT: Holds the medication and counts the respirations - Adverse effects include increased airway resistance, client is experiencing bronchospasm, should assess and then call HCP INCORRECT: Holds the medication and calls the health care provider - Should assess pt condition first!!! BOOK NOTES: Beta Blockers (pg, 61) - Adverse effects= Bradycardia, BRONCHOSPASM, Increase in HF, Fatigue and sleep disturbances - Monitor apical heart rate, cardiac rhythm, and BP - Assess for SOB and wheezing - Assess for fatigue, sleep disturbances - Assess apical HR for 1 minute before admin

Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."

CORRECT: I was unable to take my final exams because I was unable to write - client has converted the anxiety over school performance into a physical symptom that interferes with the ability to perform INCORRECT: - I love my family with all my heart, even though they don't love me= reaction formation - I don't believe I have diabetes. I feel perfectly fine= denial - If my spouse was a better housekeeper I wouldn't have such a problem= projection INTERNET NOTES: - Defense mechanism where emotional problems manifest themselves in physical symptoms - Ex. A child that witnesses a murder becomes blind.

The nurse checks the incision of the client 48 hours after surgery for a hernia repair. Which finding indicates a possible complication? 1. There is swelling under the sutures. 2. There is crusting around the incision line. 3. The incision line is red. 4. The incision line is approximated.

CORRECT: Incision line is red - Should be pink, not red, indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage INCORRECT: Swelling of the sutures - Expected during healing

The 25-year-old primigravida is diagnosed with type 1 diabetes mellitus. The nurse reviews the insulin regimen with the client. The nurse explains insulin needs will change in which way? 1. Increase during pregnancy and decrease after delivery. 2. Decrease during pregnancy and increase after delivery. 3. Increase during pregnancy and remain increased after delivery. 4. Decrease during pregnancy and fluctuate after delivery.

CORRECT: Increase during pregnancy and decrease after delivery - Needs increase during pregnancy due to hormonal interference in glucose metabolism INCORRECT: Decrease during pregnancy and increase after delivery INTERNET NOTES: - In women who do not have or develop diabetes, blood glucose levels remain stable because the pancreas is able to produce more insulin to accommodate the increased demand. - In women with preexisting diabetes, or who develop gestational diabetes, the pancreas cannot keep up with the increased demand, so blood glucose levels rise unless steps are taken to lower them

The nurse obtains the client's temperature of 103° F (39.4° C). The nurse knows body compensatory mechanisms include which mechanism? 1. Decreased respiratory rate and bradycardia. 2. Normal blood pressure and pulse. 3. Increased respiratory rate and tachycardia. 4. Diaphoresis with cool, clammy skin.

CORRECT: Increased respiratory rate and tachycardia - Hyperthermia increases the O2 requirements, which results in faster breathing as well as an increase in the pulse rate INCORRECT: Diaphoresis with cool, clammy skin - diaphoresis may occur, but the skin will be warm

The nurse teaches nutrition classes at the community center. Which food does the nurse encourage the low-income client to eat to satisfy essential protein needs? 1. Legumes. 2. Red meat. 3. Seafood. 4. Cheese.

CORRECT: Legumes - Economical source rich in protein INCORRECT: Red meat - High in protein but expensive to purchase

The client is admitted to the hospital for a hemiglossectomy with lymph node dissection. The client's preoperative care includes frequent oral hygiene with normal saline. The nurse knows the purpose of this treatment includes which reason? 1. Minimizes the bacterial count in the mouth. 2. Softens the mucous membranes of the tongue before surgery. 3. Stimulates the microcirculation of the mouth. 4. Hydrates the tissues of the gums.

CORRECT: Minimizes the bacterial count in the mouth - Destroys bacteria found in mouth, reduces chance of infection INCORRECT: - Softens the mucous membranes of the tongue before surgery= not action of saline - Stimulates the microcirculation of the mouth= circulation unaffected by mouth rinse - Hydrates tissue of gums= slight drying effect on membranes

The nurse cares for the elderly client diagnosed with dementia. Which nursing action is best? 1. Place the client in soft hand restraints or chair restraints. 2. Monitor wandering behaviors during a 7-day period. 3. Keep the lounge's television volume on a low level. 4. Encourage a diet high in protein, iron, and vitamins.

CORRECT: Monitor wandering behaviors during a 7-day period - Appropriate assessment to determine if client wander during specific times of the day; assess before implement!!!! INCORRECT: Keep the lounge's television volume on a low level - Need to prevent sensory overload, should assess first

The 11-year-old child falls off a bicycle and sustains a minor head injury. The injury is treated at the outpatient clinic. The nurse instructs the child's parent about care at home. The nurse determines further teaching is needed if the parent makes which statement? 1. "My child may have dizziness for 24 hours." 2. "My child can drink carbonated beverages if vomiting occurs." 3. "My child may report feeling nauseated." 4. "My child will probably have a headache."

CORRECT: My child can drink carbonated beverages if vomiting occurs - Vomiting is unexpexted; should be reported to HCP immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache INCORRECT: My child will probably have a HA - Expected for at least 24 hours; should not get more intense

The client takes phenelzine. The nurse observes the client eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1. Buspirone. 2. Fluoxetine. 3. Prochlorperazine. 4. Nifedipine.

CORRECT: Nifedipine - ANTIHYPERTENSIVE, pt experiencing hypertensive crisis due to ingesting tyramine; adverse effects include dizzy, HA, nervousness INCORRECT: - Buspirone= antianxiety; adverse effects include light-headedness, confusion, hypotension, palpitations - Fluoxetine= SSRI antidepressant; adverse effects include palpitation, bradycardia, nausea and vomiting

The nurse cares for the child who is in Buck's traction. The nurse notes the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse takes which action? 1. Records the observation. 2. Encourages the child to move the foot. 3. Covers the colder foot with a sock. 4. Notifies the health care provider.

CORRECT: Notifies HCP - Assessment indicates the elastic bandage is too tight and needs readjusting; CIRCULATION PROBLEM

The client has an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L (3.0 mmol/L). The client has digoxin ordered. Which nursing action is best? 1. Give the digoxin. 2. Hold the digoxin. 3. Notify the health care provider. 4. Recheck the pulse.

CORRECT: Notify HCP - Hypokalemia can precipitate dig toxicity, HCP should be called to obtain order for K+ supplement INCORRECT: Hold the dig - Notify HCP about potassium level

The infant is admitted with vomiting and diarrhea. The infant's anterior fontanelle is depressed and the temperature is 103.2° F (39.5° C). Which nursing action is most appropriate? 1. Obtain daily weights and evaluate weight loss. 2. Observe the infant's ability to take in fluids. 3. Place a full bottle of pediatric electrolyte solution at the bedside. 4. Start an intravenous infusion.

CORRECT: Observe infant's ability to take in fluids - Assessment; will assist in determining if hydration can be done through oral fluids alone INCORRECT: Start an intravenous infusion - Implementation, a later action, have to find out WHY baby is dehydrated first

The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding? 1. Sensation loss in an upper extremity. 2. Clonic jerks in the affected foot. 3. Paresthesia in the affected leg. 4. Chorea in the upper and lower extremities.

CORRECT: Paresthesia in the affected leg - Lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in lower extremities INCORRECT: Sensation loss in an upper extremity. - Results from cervical lesions

The client is admitted with irritable bowel syndrome. The nurse anticipates the client's history will reflect which information? 1. Pattern of alternating diarrhea and constipation. 2. Chronic diarrhea stools occurring 10 to 12 times per day. 3. Diarrhea and vomiting with severe abdominal distention. 4. Bloody stools with increased cramping after eating.

CORRECT: Pattern of alternating diarrhea and constipation - Condition is often called spastic bowel disease, no inflammation present INCORRECT: Diarrhea and vomiting with severe abdominal distention - Refers to IBD such as UC or Crohns

The client has been taking propranolol 40 mg bid and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg tid to the client's medication regimen. It is most important for the nurse to assess the client for which symptom? 1. Tachycardia. 2. Diarrhea. 3. Peripheral edema. 4. Impotence.

CORRECT: Peripheral edema - verapamil is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure INCORRECT: - Tachycardia= causes bradycardia - Diarrhea= causes constipation - Impotence= not most imp or frequent side effect

The nurse provides care for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is most important for the nurse to take which action? 1. Assess drainage from site drains. 2. Observe dressings for signs of excessive bleeding. 3. Elevate the residual limb for no less than 40 hours. 4. Provide cast care on the affected extremity.

CORRECT: Provide cast care on the affected extremity - Cast applied to provide uniform compression, prevents pain and contractures INCORRECT: Observe dressings for signs of excessive bleeding - Rigid cast dressing frequently used to create a socket for prosthesis *drains not usually used with amputations

The nurse cares for the client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1. The client is anxious and restless. 2. There is a small amount of dark drainage on the dressing. 3. The client reports persistent pain at the operative site. 4. The skin is cool above the operative site.

CORRECT: Pt reports persistent pain at the operative site - Pain is characteristic of inflammation and infection INCORRECT: There is a small amount of dark drainage on the dressing - Expected, not indicative of infection

The older client is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which instruction about moving does the nurse give to encourage the client to participate in care? 1. "Pull up on the overhead trapeze while you push down on your right foot to lift your body." 2. "With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently." 3. "I'll raise the head of the bed 45 degrees, and then you'll lean forward and rotate your hips to the left." 4. "Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."

CORRECT: Pull up on the overhead trapeze while you push down on your right foot to lift your body - Body must move as single, straight unit

The nurse cares for the client on suicide precautions. The client verbalizes other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on this data, which nursing action is most appropriate? 1. Recommend the health care provider decrease the client's medication dosage. 2. Recommend the treatment team reevaluate the client's treatment plan. 3. Give the client privileges to walk around the hospital alone. 4. Ask the family to begin planning for the client's discharge.

CORRECT: Recommend the treatment team reevaluate the client's treatment plan - data suggest the client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture

The client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is best? 1. Encourage the client not to do anything without thinking it through very carefully. 2. Explain to the client that anything told to the nurse is kept strictly confidential. 3. Report this to staff members in order to protect the client. 4. Encourage the client to tell the nurse more about what is being felt.

CORRECT: Report to the staff members in order to protect the client - The RN must let the pt know this information will be shared with the staff so the pts safety can be preserved INCORRECT: Encourage the pt to tell the RN more about what is being felt - Does not answer the pts immediate concern or give pt accurate information about what the nurse will do

The client is diagnosed with a hiatal hernia. Which information is the nursing assessment most likely to reveal? 1. A bulge in the lower right quadrant. 2. Pain at the umbilicus radiating down into the groin. 3. A burning sensation in the midepigastric area each day before lunch. 4. Reports of awakening at night with heartburn.

CORRECT: Reports of awakening at night with heartburn - Classic symptom of hiatal hernia associated with reflux INCORRECT: A bulge in the lower right quadrant - Suggests inguinal hernia Pain at the umbilicus radiating down into the groin - Inguinal hernia A burning sensation in the midepigastric area each day before lunch - Pain usually does not develop during the day with an empty stomach BOOK NOTES: Hiatal Hernia (pg, 168-169) - Heartburn - regurgitation - dyspepsia - opening in diaphragm through which esophagus passes becomes enlarged, part of upper stomach comes up into lower portion of the thorax - admin: H2 receptor blockers, antacids, cytoprotective medications, PPIs - do not lie for at least 1 hour after meals, elevate HOB 4-8 inches when sleeping

The nurse cares for the client receiving a continuous tube feeding. Which nursing action is most appropriate? 1. Rinse the bag and change the formula every 4 hours. 2. Rinse the bag and change the formula every shift. 3. Rinse the bag and change the formula every 12 hours. 4. Rinse the bag and change the formula every 2 hours.

CORRECT: Rinse the bag and change the formula every 4 hours - There is an increased growth of organisms after 4 hours INCORRECT: Rinse bag and change formula every 12 hours - Inappropriate due to increased organism growth

The nurse cares for the client who has just had a prosthetic hip implant. The nurse places the client in which position? 1. With the affected hip internally rotated and flexed. 2. With the affected hip adducted when turned. 3. In the supine position with the knees elevated 90 degrees. 4. Side-lying with the affected hip in a position of abduction.

CORRECT: Side lying with affected hip in position of abduction - Position of ABDUCTION should be maintained INCORRECT: With affected hip internally rotated and flexed - Flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early post op period

The client has partial-thickness and full-thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed? 1. Epigastric pain. 2. Restlessness. 3. Tachypnea. 4. Lethargy.

CORRECT: Tachypnea - Body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid resulting in cool, clammy skin, tachycardia, tachypnea, and pale color INCORRECT: Lethargy - May be due to pain

The older client diagnosed with pneumonia is admitted to the medical/surgical unit. Which other client does the nurse place with the older client? 1. The 20-year-old in traction for multiple fractures of the left lower leg. 2. The 35-year-old with recurrent fever of unknown origin. 3. The 50-year-old recovering alcoholic with cellulitis of the right foot. 4. The 89-year-old with Alzheimer's disease awaiting long term care facility placement.

CORRECT: The 50-year-old recovering alcoholic with cellulitis of the right foot - Generalized nonfollicular infection that involves deeper connective tissue, both patients have infections INCORRECT: The 35-year-old with recurrent fever of unknown origin - Don't know cause of fever

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for the 5-year-old child? 1. The child plays with a large truck with another child. 2. The child talks on a toy telephone and imitates same-sex parent. 3. The child works on a puzzle with several other children. 4. The child holds and cuddles a large stuffed animal.

CORRECT: The child talks on a toy telephone and imitates same-sex parent - Imitates behavior seen at this age INCORRECT: The child plays with a large truck with another child - Cooperative play occurs in school aged children The child works on a puzzle with several other children - Too advanced The child holds and cuddles a large stuffed anima - Too regressed

The charge nurse makes client assignments on the maternity unit. The RN has been reassigned to the maternity unit from outpatient surgery. Which client does the charge nurse assign to the RN? 1. The client at 16 weeks gestation admitted with hyperemesis and receiving IV fluids. 2. The client at 26 weeks gestation in premature labor and receiving terbutaline. 3. The client at 32 weeks gestation with a placenta previa and ruptured membranes. 4. The client at 37 weeks gestation with severe preeclampsia and epigastric pain.

CORRECT: The client at 16 weeks gestation admitted with hyperemesis and receiving IV fluids - monitor IV therapy, administer antiemetics and nutritional supplements

The nurse reviews client assignments on a medical surgical unit. The nurse determines the assignment is appropriate if the nursing assistive personnel provides care for which client? 1. The client diagnosed with AIDS dementia complex and who requires a urine specimen. 2. The client reporting postoperative pain after repair of a torn rotator cuff. 3. The client diagnosed with GI bleeding due to a duodenal ulcer and who is receiving packed cells. 4. The client diagnosed with type 1 diabetes and who is receiving prednisone for a herniated disk.

CORRECT: The client diagnosed with AIDS dementia complex and who requires a urine specimen - Standard, unchanging procedure INCORRECT: - The client reporting postoperative pain after repair of a torn rotator cuff= RN - The client diagnosed with GI bleeding due to a duodenal ulcer and who is receiving packed cells= RN - The client diagnosed with type 1 diabetes and who is receiving prednisone for a herniated disk= RN

The health care provider orders morphine sulfate 8 mg IM q 3 to 4 h for pain PRN. In which situation does the nurse consider withholding the medication until further assessment is completed? 1. The client reports acute pain from a partial-thickness burn affecting the lower left leg. 2. The client's blood pressure is 140/90, pulse is 90, and respiration is 28. 3. The client's level of consciousness fluctuates from alert to lethargic. 4. The client exhibits restlessness, anxiety, and cold and clammy skin.

CORRECT: The client's level of consciousness fluctuates from alert to lethargic - morphine depresses CNS, especially respiratory center in medulla INCORRECT: The client exhibits restlessness, anxiety, and cold and clammy skin - may be result of pain

The nurse supervises care given to clients on a medical surgical unit. The nurse intervenes if which activity is observed? 1. The nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition. 2. The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition. 3. The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen. 4. The nurse wears a disposable particulate respirator when administering rifampin to the client with tuberculosis.

CORRECT: The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen - applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur INCORRECT: The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition - insulin is only medication that can be given, compatible with TPN

The 6-month-old infant has had all of the required immunizations for that age. The nurse knows this includes which immunizations? 1. Three doses of diphtheria, tetanus, and pertussis vaccine. 2. Measles, mumps, and rubella vaccine. 3. One dose of rotavirus. 4. Varicella vaccine.

CORRECT: Three doses of diphtheria, tetanus, and pertussis vaccine - the first dose of the DTaP may be given at 2 months of age; the second is given around 4 months; the third is given around 6 months INCORRECT: - Measles, mumps, and rubella vaccine= given at 12 to 15 months - One dose of rotavirus= given at age 2, 4, and 6 months - Varicella= given at 12 to 15 months

The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is most important for the nurse to have which item available? 1. Tracheostomy set. 2. Cardiac monitor. 3. IV monitor. 4. Heating pad.

CORRECT: Tracheostomy set - RISK OF LARYNGOSPASM INCORRECT: Cardiac monitor - Not the most important BOOK NOTES: Hypoparathyroidism (pg, 365) - Tetany - Muscular irritability - Clonic convulsions - Hypomagnesia - Decreased serum calcium and INCREASED PHOSPHORUS - X ray bones appear dense

The client receives tetracycline. The nurse includes which information in the teaching plan? 1. Take the medication with milk or antacids to decrease GI problems. 2. The medication should always be taken with meals. 3. Use a maximum-protection sunscreen when outdoors. 4. Crackers and juice will help decrease gastric irritation.

CORRECT: Use max protection sunscreen when outdoors - Problems related to photosensitivity, pt should wear sunscreen, wide brimmed hats, and long sleeves at risk for sun exposure INCORRECT: - Take the medication with milk or antacids to decrease GI problems= tetracyclines should never be taken with milk or antacids because inhibit the meds actions - The medication should always be taken with meals= take with full glass of water at least 1 to 2 hours after meals

The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expect the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn. 3. Want to discuss and plan meals. 4. Have a close relationship with a parent.

CORRECT: Want to discuss and plan meals - Display a marked preoccupation with food

The nurse obtains a history from the parent of the 6-year-old child with a history of epilepsy. The child was admitted with uncontrolled seizures. It is most important for the nurse to ask which question? 1. "What part of the body was affected by the seizure?" 2. "What is the family history of seizure disorders?" 3. "What was your child doing before the seizure?" 4. "How long has it been since the last episode of seizures?"

CORRECT: What was your child doing before the seizure? - seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, medications) INCORRECT: How long has it been since the last episode of seizures? - Should be included in history, but will not prevent an immediate reoccurrence

The client experiences inflammation due to rheumatoid arthritis. Which nursing statement is correct? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."

CORRECT: When inflammation is severe, decrease the number of repetitions of the exercise. - Should reduce repetitions when pt experiences more pain INCORRECT: Passive exercises are better for you than active exercises. - Active exercise are better than passive or active assistive BOOK NOTES: Rheumatoid Arthritis (pg, 328) - Contracture deformities - C reactive protein, ESR, ANA, Aspiration of synovial fluid - Heat (warm baths, moist compresses) - Splints for joints - Immunosuppressive drugs

Which is the most appropriate nursing action to take before administering captopril? 1. Check the client's apical pulse for 60 seconds. 2. Check the client's blood pressure. 3. Check the client's urine output. 4. Check the client's temperature.

CORRECT: check pts BP - Antihtn that necessitates assessment of BP before admin

The client asks what the difference is between a gastric ulcer and a duodenal ulcer. Which response does the nurse give? 1. "Gastric ulcers have an increased association with clients who experience greater psychological pressures." 2. "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 3. "Clients with gastric ulcers often gain weight, as food alleviates the pain." 4. "Antacids are seldom prescribed for clients with duodenal ulcers."

CORRECT: the pain of a duodenal ulcer usually occurs 2 to 4 hours after meals - Clients with duodenal ulcers experience pain after meals) ex. Midmorning and midafternoon INCORRECT: Gastric ulcers have an increased association with clients who experience greater psychological pressures - Refers to duodenal ulcers Clients with gastric ulcers often gain weight, as food alleviates the pain - May be malnourished because food may cause nausea and vomiting BOOK NOTES: Ulcers (pg, 171) - Food intake relieves pain - 2 o 3 hours after meal; nighttime, often in early sleeping hours PAIN - GASTRIC: vomiting relieves pain - Duodenal hypersecretion of gastric secretion - Gastric normal to hypo secretion of gastric secretion