Question Trainer 3

Review fetal heart monitor patterns *Sorry, can't attach pic of strip*

*Early deceleration (only normal one): occurs in response to compression of fetal head; uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress -baby's fhr decelerations MIRRORS mom's peak in contractions, FHR stays above 120. *Late deceleration (non-reassuring): Show decreasing fetal heart rates that corresponds to the uterine contraction; abnormal finding indicating utero-placental dysfunction -baby's FHR responds AFTER mom's contraction; more dipped in FHR from baseline; looks like a "U" *Variable decelerations: rapid in decent and commonly do not correspond to the uterine contraction patterns, found with cord compression -not uniform, FHR responds in different times; looks like a "V" *Decreased variability: flattening of the fetal baseline

The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take first? 1. Decreases the IV rate to 20 mL/h and notifies the health care provider. 2. Decreases the IV rate to 100 mL/h and continues to monitor the client. 3. Discontinues the IV and starts oxygen at 6 L/min. 4. Assesses for infiltration of the IV solution.

Correct: 1 Rationale: 20ml/hr. (aka TKO - to keep open) will keep vein open for access 2: Need to notify HCP; rate still too much since client is in fluid overload 3: IV line may be necessary, diuretics may be ordered 4: description indicates circulatory overload, not infiltration

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 Rationale: 7 y/o see death as a punishment 2: By age 9, most children begin to develop an adult concept of death and begin to understand that death is irrversible 3: preschool's concept of death 4: an adolescent's concept of death

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: 1 Rationale: Adverse effects include increased airway resistance; client is experiencing bronchospasm, should assess and then call the HCP

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 Rationale: Assess neurovascular status, check pain, pallor, paralysis, paresthesia and pulselessness 2: assessment; temp indicates decreased circulation but is subj and not most important 3: assessment but upper extremity is affected 4: implementation; should not be done d/t increase in skin irritation STRATEGY: Answers are mix of assessments and implementations; does this situation require assessment or implementation?

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: 1 Rationale: Body must move as single, straight unit 2: turning/twisting from the waist down interferes with counteraction 3: prevents proper pull of weights 4: can't turn from side to side; can only move up and down

**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: 1 Rationale: Client is able to use phone unless otherwise indicated by court order or HCP's order

**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: 1 Rationale: Compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing

**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: 1 Rationale: Condition is called spastic bowel disease; no inflammation is present 2,3: refers to inflammatory bowel diseases, such as Crohn's or ulcerative colitis 4: bloody stools do not occur with irritable bowel syndrome

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 Rationale: Contaminated gloves should be removed before answering the phone

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: 1 Rationale: Destroys bacteria found in mouth, reduces the chance of infection 4: Slight drying effect on mucous membranes

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: 1 Rationale: Legumes are an economical source rich in protein

**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: 1 Rationale: Monitor IV therapy, admin. antiemetics and nutritional supplements 2: Monitor client's response to med and status of fetus 3: prepare for delivery, closely monitor fetal response 4: indicates impending seizure, prepare for delivery STRATEGY: LPN/LVN, "pulled" RN receive stable clients with expected outcomes

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: 1 Rationale: Needs increase during pregnancy d/t hormonal interference in glucose metabolism 3: insulin will decrease after delivery 4: insulin needs increase during pregnancy

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 Rationale: 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 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: 1 Rationale: Primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis 2: promoting ventilation and preventing respiratory acidosis is better b/c it refers to ventilation rather than oxygenation STRATEGY: Think about desired outcome. Are you preventing something or correcting a problem?

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: 1 Rationale: 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

**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: 1 Rationale: Standard, unchanging procedure

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: 1 Rationale: There is an increased growth of organisms after 4 hours

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 Rationale: To facilitate healing of the surgical area, a NGT may be utilized and tube feedings may be implemented

**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: 1 Rationale: Trache set is the most important for the client's safety d/t risk for laryngospasm **S/Sx of Hypoparathyroidism: "PTH" -Paresthesia, Positive Trousseau's and Chvostek's Sign -Tetany [severe]: contraction & cramping -> bronchospasm/seizure, laryngospasm, hands/feet spasma, ECG changes Nursing Actions: -Monitor Ca (norm. 8.6-10 mg/dL) and Phosphate (norm. 2.7-45mg/dL) levels -Maintain airway in case of tetany (trache kit, O2, suction @ bedside) -Seizure Precautions -Diet: high in Ca (dairy, green leafy veg) and low in phosphate (organ meats, soft drinks, eggs) Meds: -IV Calcium (if Ca is really low), ex. Calcium gluconate -> give slowly, on cardiac monitor to watch for ECG changes; assess for infiltration/phlebitis; watch if pt is on Digoxin -Oral calcium with Vit. D (ex. Calcium Carbonate; S/E: GI upset, constipation, renal calculi, flank pain); give at separately if pt is also taking iron and thyroid hormone -Phosphate binders (ex. Aluminum carbonate -> admin. after meals) -PTH replacement (ex. Natpara) monitor Ca levels (can cause hyperCa), GI issues, N/V, paresthesia

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 Rationale: Tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area 2: Although client has permanent tracheotomy, will be able to eat normally after area has healed 3: nutritional intake will begin when bowel sounds return and client can tolerate intake 4: not specified in question that pt. is on a vent

**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: 1 Rationale: Encourages ventilation of thoughts and feelings regarding the concern

**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: 1 Rationale: first dose of DTaP may be given at 2 mos.; the second is given around 4 months and the third is given around 6 months 2: MMR is given around 12-15 months 3: Rotavirus is given at 2, 4 and 6 months 4: Varicella is given at 12-15 months

**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: 1,2,3,4 Rationale: Hypersecretion of adrenal hormones; other indications include: -weigh gain -moon face -purple striae -osteoporosis -mood swings -high susceptibility to infections

**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.

Correct: 1,2,3,4,6 Rationale: Imipramine is a tricyclic antidepressant. Fever, dry mouth, increased fatigue, n/v/d and a sore throat can be its side effects.

The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which dietary requirements should be 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: 1,3 Rationale: -impaired intestinal absorption d/t CF necessitates a diet high in protein and calories

**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. 1: The young client with blood pulsating from a cut on the right leg 2: The pregnant client who states clothing is wet. 3: The unconscious client with the right leg shorter than the left leg 4: The preschool child who is screaming and crying uncontrollably.

Correct: 1,3,2,4 Rationale: 1: Indicates arterial bleeding; apply direct pressure; high risk for shock 3:Possible hip fracture; no indication of resp. difficulty stated; client unconscious, may have other problems 2: Requires further assessmnet, could be amniotic fluid or urine 4: Stable client, no indication of any injuries STRATEGY: Id least and most stable clients

**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: Client is receiving ciproflaxacin IV, reports a fine macular rash on the chest 2: The client receiving a blood transfusion who reports a dry motuh 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

Correct: 1,3,4,2 Rationale: 1: indicates hypersensitivity reaction; should stop med and notify HCP 3: Should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires first attention 4: Lower limit of normal is 20-25 sec.; upper limit is 32-39 secs.; aPTT is within therapeutic range; therapeutic levels increase aPTT 1.5-2 times control value; should give med 2: not an immediate concern, routinetransfusion evaluation

**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: 1,4,6 Rationale: Classic symptoms include resp. failure and flaccidity d/t paralysis of the muscles and urinary retention d/t loss of sensation 5: paralysis is whole body, not one sided as in CVA

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 Rationale: 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 **Coombs test is used in prenatal testing of pregnant women. It detects antibodies against RBCs that are present unbound in the patient's serum.**

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: 2 Rationale: Appropriate assessment to determine if client wanders during specific times of the day; assess before implementing STRATEGY: The topic of the question is unstated. Read the answer choice for clues.

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: 2 Rationale: Assessment; will assist in determining if hydration can be done through oral fluids alone 1: also assessment and correct but doesn't satisfy what the question is asking 3,4: implementation STRATEGY: Does this answer require assessment or intervention? Which one is more appropriate to the situation?

**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 Rationale: Boggy uterus deviated to right indicates full bladder, encourage client to void 1: encourage client to void first 3: will increase uterine tone but full bladder is the problem 4: findings indicate a full bladder

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: 2 Rationale: Captopril is an anti-HTN that necessitates BP assessment before admin. ** Suffix -pril for ACE Inhibitor (anti-HTN)

**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 Rationale: Cerebellum maintain balance 1: temporal lobe contains auditory center; loss of hearing involve CN VII acoustic 3: CN IX, glossopharyngeal responsible for differentiation of taste

**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: 2 Rationale: Client has converted anxiety over school performance into a physical symptom that interferes with the ability to perform 1: indicates reaction formation 3: indicates denial 4: indicates projection

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: 2 Rationale: Client has mostly progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include: -tremors -tachycardia -fever -psychological problems such as confusion, delusions and hallucinations 3: schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile 4: 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 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 Rationale: Client is experiencing increased awareness of vulnerability d/t SCI; fosters increase dependency needs that are real d/t injury; is trying to determine who is consistent and trustworthy for meeting significant physical needs

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: 2 Rationale: Clients with duodenal lcers experience pain after meals (e.g. midmorning and midafternoon)

**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: 2 Rationale: 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 the restrictions are changed gradually on the basis of a full-data picture

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 Rationale: Electrodes are attached to muscles, length of time for impulse is measured **Electromyography is a diagnostic text used to evaluate and record electrical activity produced by skeletal muscle.**

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 Rationale: Feet enlarge with age, break in shoes gradually rather than all in one time, have measurements for shoes taken while standing (feet are larger) 1: should buy shoes in the afternoon when feet are larger than in the morning 4: leather shoes recommended because they "breath"; vinyl could cause foot to perspire and aggravate fungal infections

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 Rationale: Fetus produces increased insulin to match mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia 4: thermal receptors in skin are stimulated due to cold environment; increase metabolic rate; infants need to maintain normal body temp while producing min amt. of heat generated from metabolic processes; not expected with diabetic mother

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: 2 Rationale: Fiber contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis 1: regular exercise program facilitates bowel elimination 3: normal fluid intake of 1500 mL/day facilitates bowel elimination 4: laxatives used as last resort because they become habit forming

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. Glasgow coma scale. 3. Client thinking pattern. 4. Occurrence of hallucinations.

Correct: 2 Rationale: GCS best evaluates client's LOC by evaluating eye opening, motor and verbal responses 1: shows with increased ICP 2,3: more appropriate for psych client

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: 2 Rationale: Lumbar lesions can cause paresthesia, pain, muscle weakness and atrophy in the lower extremities 1: d/t cervical lesions 2: can occur with paralyzed person from SCI 4: Sign of Huntington chorea, resulting from atrophy of parts of the brain

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 Rationale: Minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast

**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: 2 Rationale: Mottling of the skin, acrocyanosis and irregular respirations at the rate of 60 breaths per minute are sx of cold stress 1: Newborn hypoglycemia is a blood glucose level less than 25 mg/dL (1.4 mmol/L). Sx include cyanosis, apnea, tachypnea, irreg. respirations, diaphoresis, jitterness, weak cry, lethargy, convulsions and coma. 3: Meconium stained amniotic fluid is associated with birth asphyxia 4: Sx of shock occur in hypovolemia

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: 2 Rationale: 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

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 Rationale: Skin is very susceptible to breakdown b/c of immobility and bodily secretions' needs numerous nursing interventions to prevent

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 Rationale: Stomach contents are acidic 1: mucus may be from lungs 3: not a safe way to check placement 4: not a reliable indication

**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 Rationale: To go down stairs, advance cane and weak leg, then strong leg; **Memory trick: the good goes up, the bad goes down Also, COAL: Cane Opposite Affected Leg**

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: 2 Rationale: Vomiting is unexpected, should be reported to HCP stat; also unexpected is blurred vision, drianage from ear or nose, weakness, slurred speech, worsening headache 1:expected for at lest 24hrs 3: expected for at least 24hrs. 4: expected for at least 24hrs; should not get more intense

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: 2 Rationale: 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.

**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: 2 Rationale: 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

**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: 2 Rationale: severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) 1: not best way to evaluate for peripheral edema 4: used for evaluating hydration

**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: 2 Rationale: Imitative behavior seen at this age 1: cooperative play occurs in school-age children 3: too advanced for this age 4: too regressed for this age

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: 2 Rationale: Client with dementia does not have cognitive abilities to learn new skills or to adapt; env't must be adapted for client with attention to safety and predictability

**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: 2,4,6 Rationale: Isophane insulin is an itermediate-acting insulin that peaks 8-12 hours after admin; this is when s/sx of hypoglycemia will occur -other answer choices r/t hyperglycemia

**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 Rationale: Able to jump both feet and stand on one foot momentarily at 30 months

**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: 3 Rationale: Applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur 2: Insulin is the only medication that can be given, compatible with TPN

**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 Rationale: B/c of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered **IVP Prep: -Schedule IVP prior to ordered barium tests or gallbladder studies using contrast dye -Ask about allergy to seafood, iodine or contrast dye. Notify HCP/radiologist. -Verify presence of a signed consent for procedure -Assess renal and fluid status, incldng. serum osmolality, creatinine, and BUN. Notify HCP is abnormal. -Instruct client to complete ordered pretest bowel prep, including prescribed laxative or cathartic the evening before the test. -Withhold food for 8 hours prior to the tests; clear liquids are allowed -Obtain baseline VS and record**

**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: 3 Rationale: 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

**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: 3 Rationale: Children in this age need simple explanations

**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 Rationale: Client should not be positioned with operative side in a dependent position or against the bed 2: decreases swelling and pain **Post-op nursing care for eye surgery: -monitor status of the eye dressing ff. surgery -maintain eye patch/eye shield in place -semi-Fowler's or Fowler's position -Lie on unaffected side (unless surgery is for detached retina) -Assess the client and medicate/assist t avoid vomiting, coughing, sneezing or straining as needed -Assess comfort and medicate or assist as necessary for complaints of an aching or scratchy sensation in the affected eye -IMMEDIATELY report any complaint of sudden, sharp eye pain to the physician. -Assess for potential surgical complications: pain/drainage in affected eye, hemorrhage with blood in anterior chamber of the eye, flashes of light, floaters or sensation of a curtain being drawn over the eye, cloudy appearance of cornea -Approach client on unaffected side -Assist with ambulation and personal care activities PRN -Admin abx, anti-inflammatory and other systemic and eye meds to prevent infxn or inflammation of the operative site, maintain oupil constriction and control intraocular pressure -Admin antiemetic meds PRN

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: 3 Rationale: Client should wear sunscreen, wide-brimmed hats and long sleeves when at risk for sun exposure d/t photosensitivity 1: should not be taken with milk or antacids 2,4: should take with full glass of water at least 1 hour before or 2 hours after meals

**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: 3 Rationale: Contrast medium is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, herniated vertebral disks

**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: 3 Rationale: Coordination is governed by the cerebellum; this test evaluates neurosensory status 1: general CNS response, not sensory involvement 2: evaluates increased intraocular pressure 4: evaluates the facial and hypoglossal nerves

**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: 3 Rationale: Decreases the chance of aspiration into the trachea

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: 3 Rationale: Displays a marked preoccupation with food

**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: 3 Rationale: Generalized nonfollicular infection that involves deeper connective tissue; both clients have infections 1: pts with fractures are considered "clean", dont place with an infectious client 2: unknown origin of fever 4: elderly are high risk for developing PNA STRATEGY: Determine transmission of organisms

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: 3 Rationale: Hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate

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 Rationale: If extravasation occurs, there is sloughing of the surrounding skin & tissue; patent IV line is essential to prevent serious adverse effects

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: 3 Rationale: MOst widely accepted examination for the presence of tardive dyskinesia 1: more appropriate for clients who are aging and chronically mentally ill 2: measure cognitive function 4: assessment tool for determining severity of aggression; usually utilized to determine, nature, severity and prevalence of aggression in an inpatient population

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: 3 Rationale: Morphine decreases CNS, esp. resp. center in medulla

**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: 3 Rationale: Nurse must let the client know this info will be shared with the staff so the client's safety can be preserved -other answer choices does not answer client's immediate concern

**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: 3 Rationale: Pain is characteristic of inflammation and infection

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: 3 Rationale: The priority is fluid volume for a neonate 1,4: NO info about swallowing nor bonding is included in the stem 2: failure to thrive is impaired growth, fluid volume is of greater concern

**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: 3 Rationale: Verapamil is a calcium channel blocker, depresses myocardial contractility, decrease work of ventricles and O2 demand, dialtes coronary arteries; when used with other anti-hypertensives can cause hypotension and heart failure 1: will cause bradycardia 2: usually causes constipation 4: not most important or frequent adverse effect

**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: 3 Rationale: When using a gravity drip, piggyback fluid level needs to be higher than primary infusion 1: Abx should be admin within 1 hour 2,4: unnecessary for safe infusion

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. Ulcerated oral mucous membranes. 4. Dry, yellowish colored skin.

Correct: 3 Rationale: d/t frequent vomiting 1,2: seen with anorexia, not bulimia

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: 3 Rationale: should be pink, not red; indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage

**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: 3 Rationale: 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 no have a significant impact on others; client does not want to repeat the act but feels compelled to do so 4: ritual is not a method of expressing anxiety but a strategy to avoid it

**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: 3 Rationale: Seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, meds) 4: should be in detailed history but will not prevent an immediate reoccurence

**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: 3 Rationale: Should reduce repetitions when client experiences more pain 1: consistency is important to maintain joint mobility 2: active exercise are better than passive or active-assistive exercises 4: should do exercises that have been prescribed for client

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: 4 Rationale: Assessment indicates the elastic bandage is too tight and needs readjusting

**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 Rationale: Before a new IV is started on this client, HCP should be called and PO meds recommended 1: Cont'd IV meds may not be necessary based on the current assessment 2: HCP should be notified if IV meds are not infusing as scheduled 3: Client has improved breathing, so IV meds may not be indicated STRATEGY: Answers are implementation. Determine the outcome of each answer. Is it desired? **Aminophylline is a bronchodilator**

**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: 4 Rationale: Cast applied to provide uniform compression, prevents pain and contractures 1: drains not usually use with amputations 2: rigid cast dressing frequently used to create a socket for prosthesis 3: elevation of the extremity for this length of time is unnecessary; rigid casting dressing prevents swelling

**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: 4 Rationale: Classic symptom of hiatal hernia associated with reflux 1,2: suggests inguinal hernia 3: pain usually does not develop during the day with an empty stomach

**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: 4 Rationale: Insulin should be administered at room temp; temp extremes should be avoided 1: "clear" (short-acting) before "cloudy" (intermediate-acting) is correct admin when mixing insulin 2: bottle of insulin should never be vigorously shaken but rather gently mixed

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 Rationale: Most imp't to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacological intervention with both sedative and mood-stabilizing meds 1: behavioral and client/milieu are an initial priority 2: just decreasing env't stimulation will not diminish client's sense of agitation and aggression; it is used in cnjunction with psychopharmacological agents

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: 4 Rationale: Position of abduction should be maintained 1,2,3: Flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period

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: 4 Rationale: Requires contact precautions d/t possible splashing of body fluids 1: airborne, needs respirator/N95 mask 2: droplet precautions, wear a mask 3: standard precautions

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 Rationale: Young children typically become restless and overactive in response to pain. Grimacing, clenching teeth, rocking and aggressive behavior may also be observed.

**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: 4 Rationale: anti-HTN; client experiencing hypertensive crisis d/t ingesting tyramine; adverse effects include dizziness, headache, nervousness 1: antianxiety; adverse effects include light-headedness, confusion, hypotension, palpitations 2: SSRI antidepressant; adverse effects include palpitation, bradycardia, N/V 3: antiemetic; adverse effect include drowsiness, orthostatic hypotension

**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. 1: The client with substance abuse reports harassment by another client. 2: The client diagnosed with bipolar walks into the day room wearing only underwear. 3: The client diagnoses with schizophrenia tells the nurse the TV should be destroyed. 4: The client diagnosed with depression says to the nurse, "My plan is complete; and I'm ready to go."

Correct: 4,1,3,2 Rationale: 4: Client diagnoses with depression could indicate impending suicide, requires immediate f/u 1: Client with substance abuse should be moved to quiet area, decrease env't stimuli, may cause a distraction for other clients 3: Client with schizo is experiencing command hallucination, protect from injury and from destroying the TV 4: Client wearing only underwear is not a harm to self nor to others initially

**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. 1: Client diagnosed with type 1 DM scheduled for cardiac cath at 1400 2: Client post-CABG having atrioventricular wires removed at 1500 3: Client diagnose with cardiomyopathy being evaluated for a heart transplant 4: Client 1 day postop with an epidural catheter in place

Correct: 4,3,1,2 Rationale: First: most unstable client with epidural needs assessment for side effects of epidural and is fresh postop respiratory consideration. Second: client needing heart transplant will be unstable requires monitoring and early assessment; circulation consideration. Third: needs assessment of blood glucose and preoperative needs but falls behind respiratory and unstable circulation. Last: stable client. STRATEGY: Look for most unstable client and work towards most stable client

**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: 3 Rationale: Hypokalemia can precipitate digoxing toxicity; HCP should be called to obtain order for potassium supplement

**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 Rationale: Test is used with a client who may have varicose veins, which have no relationship to the sx described in this situation **Trendelenburg Test: observe pt from behind, ask him/her to stand on one foot and then the other NEG-Pelvis tilts up on contralateral side POS-'sags' on contralateral side: -fracture neck of femur-dislocation of hip joint -nonfunctioning gluteus medius and minimus d/t: neuro damage(L4-L5 herniation), any disease of the muscles 1: to determine adrenal gland fx 2: check for endocrine cause for sx before diagnosing dementia 3:ordered to see if client's sx are caused by excessive use of meds or alcohol